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Gioia S, De Santis A, d'Amati G, Nardelli S, Spagnoli A, Rocco AD, Ridola L, Riggio O. Application of ultrasonography-elastography score to suspect porto-sinusoidal vascular disease in patients with portal vein thrombosis. Hepatobiliary Pancreat Dis Int 2024; 23:20-24. [PMID: 37468349 DOI: 10.1016/j.hbpd.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 07/05/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Porto-sinusoidal vascular disease (PSVD) and portal vein thrombosis (PVT) are causes of portal hypertension characterized respectively by an intrahepatic and a pre-hepatic obstacle to the flow in the portal system. As PVT may be a consequence of PSVD, in PVT patients at presentation, a pre-existing PSVD should be suspected. In these patients the identification of an underlying PSVD would have relevant implication regarding follow-up and therapeutic management, but it could be challenging. In this setting ultrasonography may be valuable in differential diagnosis. The aim of the study was to use ultrasonography to identify parameters to discriminate between PSVD and "pure" PVT and then to suspect PVT secondary to a pre-existing PSVD. METHODS Fifty-three patients with histologically proven PSVD and forty-eight patients affected by chronic PVT were enrolled and submitted to abdominal ultrasonography with elastography by acoustic radiation force impulse (ARFI). RESULTS ARFI was higher and superior mesenteric vein (SMV) diameter was wider in PSVD patients than in PVT patients. Thus, a prognostic score was obtained as linear combinations of the two parameters with a good discrimination capacity between PSVD and PVT (the area under the curve = 0.780; 95% confidence interval: 0.690-0.869). CONCLUSIONS A score based on ARFI and SMV diameter may be useful to suspect an underlying PSVD in patients with PVT and to identify a subgroup of patients to be submitted to liver biopsy.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological, and Pathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Arianna Di Rocco
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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2
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Biagi F, Carlomagno F, Carbone M, Veralli R, Vespasiani-Gentilucci U, Riva E, Manfrini S, Tuccinardi D, De Santis A, Gnessi L, Watanabe M. Fibroblast Growth Factor 21 in Chronic Hepatitis C: A Potential Non-Invasive Biomarker of Liver Status upon Viral Eradication. Metabolites 2023; 13:1119. [PMID: 37999215 PMCID: PMC10673401 DOI: 10.3390/metabo13111119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/26/2023] [Accepted: 10/27/2023] [Indexed: 11/25/2023] Open
Abstract
Fibroblast growth factor 21 (FGF-21), previously recognized as a marker of liver damage and a potential drug target in non-alcoholic fatty liver disease (NAFLD), has unclear implications in hepatitis C virus (HCV) infections. This study aimed to investigate the relationship between FGF-21 levels and liver health in patients with HCV undergoing direct-acting antiviral (DAA) treatment. Forty-five patients were assessed for liver stiffness, blood chemistry, and other relevant metrics before and after achieving sustained viral response (SVR), defined as the absence of detectable HCV-RNA after 24 weeks of treatment. Post-treatment, all patients showed a decrease in liver stiffness and improved liver enzyme levels (AST and ALT), alongside an increase in FGF-21 levels. Interestingly, the increase in FGF-21 correlated negatively with liver stiffness but showed no correlation with hepatic steatosis. The observed elevation in FGF-21 levels at SVR following DAA therapy for chronic HCV infection can be attributed to the restoration of hepatic function, including its synthetic capabilities. Specifically, the mitigation of liver fibrosis post-HCV eradication is expected to lead to improvements in liver function, such as enhanced albumin and FGF-21 production. This improvement in synthetic function likely drives the increase in FGF-21 levels, rather than changes in liver fat content. We suggest a potential role of FGF-21 as a marker of fibrosis and hepatic cytotoxicity and as a drug target beyond NAFLD, to be confirmed by additional studies.
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Affiliation(s)
- Filippo Biagi
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy (F.C.); (M.W.)
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy
| | - Francesco Carlomagno
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy (F.C.); (M.W.)
| | - Martina Carbone
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy (A.D.S.)
- Department of General Surgery, Section of Gastroenterology, Azienda Sanitaria Universitaria Friuli Centrale–P.O. Santa Maria della Misericordia di Udine, 33100 Udine, Italy
| | - Roberta Veralli
- Clinical Laboratory Unit, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy;
- Unit of Virology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | | | - Elisabetta Riva
- Unit of Virology, Fondazione Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
- Department of Medicine and Surgery, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Silvia Manfrini
- Department of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy (A.D.S.)
| | - Lucio Gnessi
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy (F.C.); (M.W.)
| | - Mikiko Watanabe
- Department of Experimental Medicine, Section of Medical Pathophysiology, Food Science and Endocrinology, Sapienza University of Rome, 00161 Rome, Italy (F.C.); (M.W.)
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Parisse S, Carnevale S, Di Bartolomeo F, Poli E, Miceli F, Ferri F, Mischitelli M, Rocco B, Lai Q, Lucatelli P, Corona M, Mennini G, De Santis A, Rossi M, Muscaritoli M, Cantafora A, Ginanni Corradini S. A Low Daily Intake of Simple Sugars in the Diet Is Associated with Improved Liver Function in Cirrhotic Liver Transplant Candidates. Nutrients 2023; 15:nu15071575. [PMID: 37049416 PMCID: PMC10097197 DOI: 10.3390/nu15071575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/19/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
(1) Background: We investigated, for the first time, whether dietary simple sugar intake affects MELD score changes over time in a cohort of cirrhotic liver transplant candidates. (2) Methods: the MELD score, dietary habits using a 3-day food diary, and visceral adipose tissue index (VATI) measured with CT scan were assessed in 80 consecutive outpatient cirrhotic patients at baseline, after counseling to follow current nutritional guidelines. The MELD score was reassessed after six months and the DELTA-MELD was calculated as the MELD at the second assessment minus the MELD at baseline. (3) Results: Compared with the baseline, the MELD score of cirrhotic patients at the end of the study was decreased, stable, or increased in 36%, 8% and 56% of patients, respectively. In separate multiple linear regression models, DELTA-MELD was positively and independently correlated with the daily intake of simple sugars expressed in g/kg body weight (p = 0.01) or as a percentage of total caloric intake (p = 0.0004) and with the number of daily portions of fruit, added sugar, jam, and honey (p = 0.003). These associations were present almost exclusively in patients with VATI above the median value. (4) Conclusions: In cirrhotic patients with high amounts of visceral adipose tissue the consumption of simple sugars and fructose should be limited to improve their clinical outcome.
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Affiliation(s)
- Simona Parisse
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | | | - Francesca Di Bartolomeo
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Edoardo Poli
- Centre Hépato-Biliaire, Hôpital Paul Brousse, AP-HP, 94800 Villejuif, France
| | - Francesca Miceli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Monica Mischitelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Bianca Rocco
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Pierleone Lucatelli
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Mario Corona
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Gianluca Mennini
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Department of Surgery, Sapienza University of Rome, 00161 Rome, Italy
| | - Maurizio Muscaritoli
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
| | - Alfredo Cantafora
- Department of Translational and Precision Medicine, Sapienza University of Rome, 00185 Rome, Italy
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Vescovo M, Pesci L, Lapenna L, De Santis E, Di Nardo D, de Anna L, Mongardini FM, Ascoli V, Mongardini M, De Santis A, Giordano C. Severe rectal prolapse and solitary rectal ulcer in a young anorectic woman with myxoid degeneration of visceral adipose tissue. Pathologica 2022; 113:475-480. [PMID: 34974555 PMCID: PMC8720390 DOI: 10.32074/1591-951x-253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/27/2021] [Indexed: 11/30/2022] Open
Abstract
Rectal prolapse is a disorder in which the rectum protrudes from the anal canal. Solitary rectal ulcer may coexist. Both conditions have been associated with chronic constipation and excessive straining during defecation. Rectal prolapse has been rarely reported in women suffering from anorexia nervosa. Lack of rectal support because of loss of ischiorectal fat has been proposed as one of the possible mechanisms in this condition, together with chronic constipation and abuse of laxative. We report the case of an anorexic woman with a severe rectal prolapse and bleeding requiring urgent Altmeier’s procedure. Surgery was complicated by dehiscence of the anastomosis and volvulus, requiring ileostomy and laciniae debridement. Pathological analysis of all the surgical samples taken from different abdominal sites highlighted changes in the visceral adipose tissue consisting in nodular aggregates of small adipocytes dispersed in a myxoid matrix surrounding blood vessels within abundant fibrosis. The morphologic features resemble those observed in primordial fetal fat and are comparable to those observed in cancer associated cachexia. The diffuse myxoid degeneration of visceral adipose tissue may play a role in the pathogenesis of rectal prolapse in patients with anorexia nervosa. Besides starvation, the mechanism sustaining myxoid degeneration of the adipose tissue is not entirely clear. Whenever possible improving nutritional and clinical conditions should be ideal before any surgical approach.
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Affiliation(s)
- Mariavittoria Vescovo
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Ludovica Pesci
- Department of Precision and Translation Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Lucia Lapenna
- Department of Precision and Translation Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Emanuela De Santis
- Department of Precision and Translation Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Domenico Di Nardo
- Department of General and Plastic Surgery, and Orthopedics, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Livia de Anna
- Department of General and Plastic Surgery, and Orthopedics, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Federico Maria Mongardini
- Department of General and Plastic Surgery, and Orthopedics, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Valeria Ascoli
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Massimo Mongardini
- Department of General and Plastic Surgery, and Orthopedics, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Adriano De Santis
- Department of Precision and Translation Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Carla Giordano
- Department of Radiological, Oncological and Pathological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
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De Santis A, Maggi D, Lubrano Lobianco F. Safety and efficacy of directly-acting antiviral therapy for chronic hepatitis C virus in elderly people. Aging Med (Milton) 2021; 4:304-316. [PMID: 34964012 PMCID: PMC8711222 DOI: 10.1002/agm2.12190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION In Italy, the prevalence of hepatitis C virus (HCV) infection is higher in the elderly, although the efficacy and safety of treatment in this population has not been extensively studied. Moreover, little is known about how much pharmacological interaction affects eligibility to treatment and to what extent the treatment affects subsequent outcomes. METHODS We retrospectively analyzed the efficacy and safety of directly acting antivirals (DAAs), drug-to-drug interactions, and post-treatment outcomes in 138 patients with HCV aged 70 years or older, who were consecutively treated in our center between 2015 and 2020. RESULTS The mean age was 77 years old (range = 70-95 years old). The Cumulative Illness Rating Scale of pretherapy severity was classified as moderate to severe in 65% of patients. Fifty-five patients (40%) presented compensated cirrhosis, eight of which were complicated by hepatocellular carcinoma (HCC) and all were cured before treatment. One hundred two patients (74%) were taking two or more drugs (range = 0-5 concomitant drugs registered) and in 29 patients (21%) we found potential drug-to-drug interaction. In 11 of those 29 patients (38%), we were forced to change the chronic therapy, when all therapeutic regimens were equal in terms of efficacy and interactions, to avoid potentially serious drug interactions. One serious adverse event occurred in our sample population (i.e., diverticular bleeding due to interaction with direct oral anticoagulants [DOACs]), whereas mild side effects occurred in 37% of patients. The undetectability of HCV RNA at the end of treatment was achieved in 97% of patients, whereas a sustained virological response (SVR) 12 and SVR 24 were obtained in 98% of patients. When comparing pretherapy with post-therapy data, after a medium follow-up of 15 months (median = 1 year, minimum = 2 months, and maximum = 4 years), we observed a reduction in the incidence of episodes of liver decompensation in patients with cirrhosis and a slight increase in the incidence of HCC (with 6 recurrent and 5 de novo HCC), diagnosed within 13 months from the end of therapy. In all patients, we found a significant improvement in all ultrasound variables and a significant reduction in the elastographic measurements. No significant differences in outcomes were observed dividing the population into patients aged ≥ 80 and < 80 years old. CONCLUSIONS Directly acting antiviral therapy was found to be safe and effective in elderly people, and, despite the large number of concomitant drugs, pharmacological interactions appeared to not affect the adherence to therapy or the incidence of adverse events. Side effects were mostly independent from the type of DAA used and from the burden of comorbidity. In long-term follow-up, the benefit of DAA therapy mainly concerned liver pathology and should be strongly advised in patients with cirrhosis. The therapy was found to not affect extrahepatic comorbidities but allowed to end follow-up in noncirrhotic patients with savings in terms of resources. Finally, patients should not be excluded based on age if they have a good performance status.
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Affiliation(s)
- Adriano De Santis
- Department of Translational and Precision MedicineSapienza UniversityRomeItaly
| | - Daniela Maggi
- Department of Translational and Precision MedicineSapienza UniversityRomeItaly
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Corica B, Cacciani A, Cangemi R, Visentini M, Recchia F, Grillo R, Vano M, Sperduti N, Cincione A, Buoninfante G, Pulcinelli F, Chistolini A, De Santis A, Flego D, Romiti GF, Basili S, Stefanini L. Clinical course, management, and platelet activity assessment of splanchnic VITT: A case report. Thromb Res 2021; 208:14-17. [PMID: 34673368 PMCID: PMC8513518 DOI: 10.1016/j.thromres.2021.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/14/2021] [Accepted: 10/11/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Bernadette Corica
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | | | - Roberto Cangemi
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Fabrizio Recchia
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Rosalba Grillo
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marco Vano
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Nicolò Sperduti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Alessandro Cincione
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Giovanni Buoninfante
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Fabio Pulcinelli
- Department of Experimental Medicine, Sapienza - University of Rome, Rome, Italy
| | - Antonio Chistolini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Davide Flego
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy.
| | - Lucia Stefanini
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
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Lattanzi B, Bruni A, Di Cola S, Molfino A, De Santis A, Muscaritoli M, Merli M. The Effects of 12-Week Beta-Hydroxy-Beta-Methylbutyrate Supplementation in Patients with Liver Cirrhosis: Results from a Randomized Controlled Single-Blind Pilot Study. Nutrients 2021; 13:nu13072296. [PMID: 34371806 PMCID: PMC8308449 DOI: 10.3390/nu13072296] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/28/2021] [Accepted: 06/28/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Aim: Sarcopenia is considered an important risk factor for morbidity and mortality in liver cirrhosis. Beta-hydroxy-beta-methylbutyrate (HMB) has the potential to increase muscle mass and performance by stimulating protein synthesis and reducing muscle catabolism. The present study aimed at evaluating the effect of HMB supplementation on muscle mass and function in patients with liver cirrhosis. Changes in frailty during the study were also estimated, and the safety of HMB supplementation was verified. Methods: This is a randomized, single-blind, placebo-controlled pilot trial. Twenty-four patients (14 HMB and 10 placebo) affected by liver cirrhosis were enrolled in the study. Each patient received dedicated counseling, which included nutrition and physical activity recommendations for chronic liver disease patients. Patients were randomized to receive 3 g/day of HMB or placebo (sorbitol powder) for 12 consecutive weeks. A diet interview, anthropometry, electrical bioimpedance analysis (BIA), quadriceps ultrasound, physical performance battery, Liver Frailty Index (LFI), and cognitive tests were completed at enrolment (T0), at 12 weeks (T1), and 24 weeks after enrolment (T2). Results: At baseline, the two groups were similar in demography, severity of liver disease, muscle mass, muscle function, and cognitive tests. LFI at baseline was higher in patients in the HMB group vs. those in the placebo group (4.1 ± 0.4 vs. 3.4 ± 0.6, p < 0.01). After treatment, a statistically significant increase in muscle function was seen in the HMB group (chair stand test: 14.2 ± 5 s vs. 11.7 ± 2.6 s, p < 0.05; six-minute walk test: 361.8 ± 68 m vs. 409.4 ± 58 m, p < 0.05). Quadriceps muscle mass measured by ultrasound also increased (4.9 ± 1.8 vs. 5.4 ± 1.8 mm, p < 0.05) after HMB, while LFI decreased (4.1 ± 0.4 vs. 3.7 ± 0.4, p < 0.05). HMB was well tolerated by patients, and no adverse events were documented. Conclusions: Our study suggests the efficacy of 12-week beta-hydroxy-beta-methylbutyrate supplementation in promoting improvements in muscle performance in compensated cirrhotic patients. LFI was also ameliorated. Further studies with a greater number of patients are required to reinforce this hypothesis.
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Affiliation(s)
- Barbara Lattanzi
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Angelo Bruni
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Simone Di Cola
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Alessio Molfino
- Internal Medicine, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (A.M.); (M.M.)
| | - Adriano De Santis
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
| | - Maurizio Muscaritoli
- Internal Medicine, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (A.M.); (M.M.)
| | - Manuela Merli
- Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University, 00185 Rome, Italy; (B.L.); (A.B.); (S.D.C.); (A.D.S.)
- Correspondence: ; Tel.: +39-(06)-49972001
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8
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de Salazar A, Dietz J, di Maio VC, Vermehren J, Paolucci S, Müllhaupt B, Coppola N, Cabezas J, Stauber RE, Puoti M, Arenas Ruiz Tapiador JI, Graf C, Aragri M, Jimenez M, Callegaro A, Pascasio Acevedo JM, Macias Rodriguez MA, Rosales Zabal JM, Micheli V, Garcia Del Toro M, Téllez F, García F, Sarrazin C, Ceccherini-Silberstein F, Canbay A, Port K, Cornberg M, Manns M, Reinhardt L, Ellenrieder V, Zizer E, Dikopoulos N, Backhus J, Seufferlein T, Beckebaum S, Hametner S, Schöfl R, Niederau C, Schlee P, Dreck M, Görlitz B, Hinrichsen H, Seegers B, Jung M, Link R, Mauss S, Meister V, Schnaitmann E, Sick C, Simon KG, Schmidt KJ, Andreoni M, Craxì A, Giaccone P, Perno CF, Zazzi M, Bertoli A, Angelico M, Masetti C, Giannelli V, Camillo S, Begini P, De Santis A, Taliani G, Lichtner M, Rossetti B, Caudai C, Cozzolongo R, De Bellis S, Starace M, Minichini C, Gaeta G, Pisaturo MA, Messina V, Dentone C, Bruzzone B, Landonio S, Magni C, Merli M, De Gasperi E, Policlinico GOM, Hasson H, Boeri E, Beretta I, Molteni C, Maffezzini AME, Dorigoni N, Guella L, Götze T, Canbay A, Port K, Cornberg M, Manns M, Reinhardt L, Ellenrieder V, Zizer E, Dikopoulos N, Backhus J, Seufferlein T, Beckebaum S, Hametner S, Schöfl R, Niederau C, Schlee P, Dreck M, Görlitz B, Hinrichsen H, Seegers B, Jung M, Link R, Mauss S, Meister V, Schnaitmann E, Sick C, Simon KG, Schmidt KJ, Andreoni M, Craxì A, Giaccone P, Perno CF, Zazzi M, Bertoli A, Angelico M, Masetti C, Giannelli V, Camillo S, Begini P, De Santis A, Taliani G, Lichtner M, Rossetti B, Caudai C, Cozzolongo R, De Bellis S, Starace M, Minichini C, Gaeta G, Pisaturo MA, Messina V, Dentone C, Bruzzone B, Landonio S, Magni C, Merli M, De Gasperi E, Policlinico GOM, Hasson H, Boeri E, Beretta I, Molteni C, Maffezzini AME, Dorigoni N, Guella L. Prevalence of resistance-associated substitutions and retreatment of patients failing a glecaprevir/pibrentasvir regimen. J Antimicrob Chemother 2021; 75:3349-3358. [PMID: 32772078 DOI: 10.1093/jac/dkaa304] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/02/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To investigate resistance-associated substitutions (RASs) as well as retreatment efficacies in a large cohort of European patients with failure of glecaprevir/pibrentasvir. METHODS Patients were identified from three European Resistance Reference centres in Spain, Italy and Germany. Sequencing of NS3, NS5A and NS5B was conducted and substitutions associated with resistance to direct antiviral agents were analysed. Clinical and virological parameters were documented retrospectively and retreatment efficacies were evaluated. RESULTS We evaluated 90 glecaprevir/pibrentasvir failures [3a (n = 36), 1a (n = 23), 2a/2c (n = 20), 1b (n = 10) and 4d (n = 1)]. Ten patients were cirrhotic, two had previous exposure to PEG-interferon and seven were coinfected with HIV; 80 had been treated for 8 weeks. Overall, 31 patients (34.4%) failed glecaprevir/pibrentasvir without any NS3 or NS5A RASs, 62.4% (53/85) showed RASs in NS5A, 15.6% (13/83) in NS3 and 10% (9/90) in both NS5A and NS3. Infection with HCV genotypes 1a and 3a was associated with a higher prevalence of NS5A RASs. Patients harbouring two (n = 34) or more (n = 8) RASs in NS5A were frequent. Retreatment was initiated in 56 patients, almost all (n = 52) with sofosbuvir/velpatasvir/voxilaprevir. The overall sustained virological response rate was 97.8% in patients with end-of-follow-up data available. CONCLUSIONS One-third of patients failed glecaprevir/pibrentasvir without resistance. RASs in NS5A were more prevalent than in NS3 and were frequently observed as dual and triple combination patterns, with a high impact on NS5A inhibitor activity, particularly in genotypes 1a and 3a. Retreatment of glecaprevir/pibrentasvir failures with sofosbuvir/velpatasvir/voxilaprevir achieved viral suppression across all genotypes.
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Affiliation(s)
- Adolfo de Salazar
- Clinical Microbiology Unit, University Hospital San Cecilio, Instituto de Investigacion Ibs.Granada. Granada, Spain
| | - Julia Dietz
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany; German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Velia Chiara di Maio
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Johannes Vermehren
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany; German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Stefania Paolucci
- Molecular Virology Unit, Microbiology and Virology Department, IRCCS Policlinic Foundation San Matteo, Pavia, Italy
| | - Beat Müllhaupt
- Swiss Hepato-Pancreato-Biliary Center and Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Nicola Coppola
- Department of Mental Health and Public Medicine, Infectious Diseases Unit, University of Campania "L. Vanvitelli", Naples, Italy
| | - Joaquín Cabezas
- Department of Hepatology, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Rudolf E Stauber
- Department of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Massimo Puoti
- Infectious Diseases, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Christiana Graf
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany; German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Marianna Aragri
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Miguel Jimenez
- Hepatology Unit, Hospital Regional de Málaga, Málaga, Spain
| | | | | | | | | | - Valeria Micheli
- Clinical Microbiology, Virology and Bioemergencies, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | | | - Francisco Téllez
- Infectious Diseases Unit, Hospital Puerto Real, Puerto Real, Cádiz, Spain
| | - Federico García
- Clinical Microbiology Unit, University Hospital San Cecilio, Instituto de Investigacion Ibs.Granada. Granada, Spain
| | - Christoph Sarrazin
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt, Germany; German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany.,Medizinische Klinik 2, St. Josefs Hospital, Wiesbaden, Germany
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9
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Paparella D, Santarpino G, Moscarelli M, Guida P, De Santis A, Fattouch K, Martinelli L, Coppola R, Mikus E, Albertini A, Del Giglio M, Gregorini R, Speziale G. Minimally invasive aortic valve replacement: short-term efficacy of sutureless compared with stented bioprostheses. Interact Cardiovasc Thorac Surg 2021; 33:188-194. [PMID: 33984125 DOI: 10.1093/icvts/ivab070] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Sutureless aortic valve prostheses have been introduced to facilitate the implant process, speed up the operating time and improve haemodynamic performance. The goal of this study was to assess the potential advantages of using sutureless prostheses during minimally invasive aortic valve replacement in a large multicentre population. METHODS From 2011 to 2019, a total of 3402 patients in 11 hospitals underwent isolated aortic valve replacement with minimal access approaches using a bioprosthesis. A total of 475 patients received sutureless valves; 2927 received standard valves. The primary outcome was the incidence of 30-day deaths. Secondary outcomes were the occurrence of major complications following procedures performed with sutureless or standard bioprostheses. Propensity matched comparisons was performed based on a multivariable logistic regression model. RESULTS The annual number of sutureless valve implants increased over the years. The matching procedure paired 430 sutureless with 860 standard aortic valve replacements. A total of 0.7% and 2.1% patients with sutureless and standard prostheses, respectively, died within 30 days (P = 0.076). Cross-clamp times [48 (40-62) vs 63 min (48-74); P = 0.001] and need for blood transfusions (27.4% vs 33.5%; P = 0.022) were lower in patients with sutureless valves. No difference in permanent pacemaker insertions was observed in the overall population (3.3% vs 4.4% in the standard and sutureless groups; P = 0.221) and in the matched groups (3.6% vs 4.7% in the standard and sutureless groups; P = 0.364). CONCLUSIONS The use of sutureless prostheses is advantageous and facilitates the adoption of a minimally invasive approach, reducing cardiac arrest time and the number of blood transfusions. No increased risk of permanent pacemaker insertion was observed.
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Affiliation(s)
- Domenico Paparella
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy.,Dipartimento Scienze Medice e Chirurgiche, Università di Foggia, Foggia, Italy
| | - Giuseppe Santarpino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy.,Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University, Nuremberg, Germany
| | - Marco Moscarelli
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Pietro Guida
- Regional General Hospital "F. Miulli", Acquaviva delle Fonti, Italy
| | - Adriano De Santis
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Khalil Fattouch
- Department of Cardiac Surgery, Maria Eleonora Hospital, GVM Care & Research, Palermo, Italy
| | - Luigi Martinelli
- Department of Cardiac Surgery, ICLAS, GVM Care & Research, Rapallo, Italy
| | - Roberto Coppola
- Department of Cardiac Surgery, ICLAS, GVM Care & Research, Rapallo, Italy
| | - Elisa Mikus
- Department of Cardiac Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Alberto Albertini
- Department of Cardiac Surgery, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Mauro Del Giglio
- Department of Cardiac Surgery, Villa Torri Hospital, GVM Care & Research, Bologna, Italy
| | - Renato Gregorini
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care & Research, Lecce, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
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10
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Pugliese N, Giorgini A, Maggi D, Capogreco A, Dibenedetto C, Lubrano Lobianco F, Dal Buono A, Monico S, Meli R, Battezzati PM, Lleo A, De Santis A, Zuin M, Aghemo A. Directly acting antivirals are safe and effective in HCV positive patients aged 80 years and older: a multicenter real-life study. Expert Opin Drug Saf 2021; 20:839-843. [PMID: 33881366 DOI: 10.1080/14740338.2021.1921144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Treatment of chronic Hepatitis C with directly acting antivirals (DAAs) can bring to sustained virologic response (SVR) in approximately 95% of patients. Efficacy and safety of DAAs in aging patients has not been widely analyzed. We aimed to determine safety and efficacy of DAA-based regimens in a cohort of elderly patients in a real-life setting.Research Design and Methods: We retrospectively investigated safety and efficacy of DAAs in HCV patients of 80 years or older treated in three Hepatology Units.Results and Expert opinion: During the study period, 170 patients older than 80 years received DAAs. Their mean age was 82,3 years. The predominant HCV genotype was 1 (100 patients, 59%). Among the 93 cirrhotic patients (54,7%), 18 had CPT score > A5. Different DAAs regimens were used. Concomitant drugs were common: 163 patients (95,8%) taking at least one drug. In 11 patients, usual therapy had to be changed to start antiviral treatment. Two serious adverse events occurred. Four patients terminated treatment prematurely. In total, 45 patients (26,5%) testified mild side effects. HCV-RNA undetectability at week 12 of treatment follow-up was achieved in 168/170 patients. DAA treatment in HCV patients of 80 years or older is efficacious and safe. Drug-drug interaction should be judiciously evaluated before starting therapy.
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Affiliation(s)
- Nicola Pugliese
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessia Giorgini
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Daniela Maggi
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Antonio Capogreco
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Clara Dibenedetto
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | | | - Arianna Dal Buono
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Sara Monico
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Rossella Meli
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Pier Maria Battezzati
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Ana Lleo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Massimo Zuin
- Liver and Gastroenterology Unit, Department of Health Sciences, Universita' degli Studi di Milano, DeparmtASST Santi Paolo E Carlo, University Hospital San Paolo, Milan, Italy
| | - Alessio Aghemo
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
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11
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Paparella D, De Santis A. Minimally invasive redo aortic valve replacement with a sutureless valve implant. Multimed Man Cardiothorac Surg 2021; 2021. [PMID: 33691045 DOI: 10.1510/mmcts.2021.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Reoperations for a dysfunctional mechanical aortic valve prosthesis are usually performed with a repeat sternotomy. Reopening the chest may be associated with a heart structure tear, bleeding, excessive transfusion, and a possible unfavorable outcome. Experience performing a redo aortic valve replacement with a minimally invasive approach and avoiding lysis of the pericardial adhesions is growing. We describe a redo aortic valve replacement procedure performed because of subvalvular pannus formation in a patient with a mechanical prosthesis. A partial J-shaped hemisternotomy at the 3rd intercostal space was performed; the ascending aorta was exposed and the valve was replaced with a sutureless bioprosthesis. The video tutorial shows the surgical approach, cardiopulmonary bypass solutions, and sutureless valve deployment.
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Affiliation(s)
- Domenico Paparella
- University of Foggia, Department of Medical and Surgical Science, Foggia, Italy. Santa Maria Hospital, Division of Cardiac Surgery, Bari, Italy
| | - Adriano De Santis
- Santa Maria Hospital Bari, Italy; University "Luigi Vanvitelli Napoli" & Faculty of Medicine, Italy
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12
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Margari V, Malvindi PG, De Santis A, Kounakis G, Visicchio G, Mastrototaro G, Dambruoso P, Carbone C, Paparella D. Minimally invasive tricuspid valve surgery without caval occlusion: Short and midterm results. J Card Surg 2021; 36:618-623. [PMID: 33403735 DOI: 10.1111/jocs.15278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/06/2020] [Accepted: 12/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The use of minimally invasive or transcatheter interventions rather than standard full sternotomy operations to treat tricuspid valve (TV) disease is increasing. The debate however is still open regarding venous drainage management during cardiopulmonary bypass (CPB) and wheatear or not superior and inferior vena cava should be occluded during the opening of the right atrium to avoid air entrance in the venous line. The aim of the present study is to report operative outcomes and midterm follow-up results of minimally invasive TV surgery performed without caval occlusion. METHODS A retrospective outcome evaluation from institutional records was performed with prospective data entry. Considered were consecutive patients who underwent right mini-thoracotomy TV surgery isolated or combined with mitral valve surgery during the period from June 2013 to February 2020. A telephone and echocardiographic follow-up was performed. RESULTS During the study period, 68 consecutive patients underwent minimally invasive TV surgery without occlusion of cava veins. The mean age was 69 ± 14 years and 48 (70%) were female. All operations were performed safely without air-lock during CPB. A perioperative cerebral stroke occurred in one patient. The survival at a 5- and 8-year follow-up was 100% and 79%, respectively. No severe tricuspid regurgitation was evident at echocardiographic follow-up. CONCLUSION Our results show that performing tricuspid surgery without caval occlusion is safe. The air was captured by the active vacuum drainage system without causing damage. Midterm follow-up data confirm that a minimally invasive approach does not alter the quality of surgery.
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Affiliation(s)
- Vito Margari
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Pietro G Malvindi
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Adriano De Santis
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Giorgio Kounakis
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Giuseppe Visicchio
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Giuseppe Mastrototaro
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Pierpaolo Dambruoso
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Carmine Carbone
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Domenico Paparella
- Department of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy.,Dipartimento Scienze Mediche e Chirurgiche, Università di Foggia, Foggia, Italy
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13
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Colantuono S, Marrapodi R, Del Padre M, Collalti G, Garzi G, De Santis A, Fiorilli M, Basili S, Visentini M, Casato M. Clinico-immunological outcomes of HCV-cured cryoglobulinemia: Lower relapse rate with interferon-based than interferon-free therapy. Liver Int 2021; 41:70-75. [PMID: 33064930 DOI: 10.1111/liv.14698] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/01/2020] [Accepted: 10/06/2020] [Indexed: 12/13/2022]
Abstract
Sustained virological response (SVR) obtained with interferon (IFN) or with direct-acting antivirals (DAAs) is commonly followed by response of hepatitis C virus (HCV)-associated mixed cryoglobulinemia vasculitis (MCV), but relapse of MCV despite SVR has been reported in several patients after DAAs and rarely after IFN. Since relapses could have been overlooked in studies with IFN, we retrospectively compared the outcomes of MCV in SVR patients treated with DAAs (n = 70) or IFN (n = 39) followed-up, respectively, for 30.5 (range 11-51) or 48 months. Groups were comparable for demographics and clinics and response rates of MCV were similar (92% and 86%); however, DAA-treated patients less efficiently reduced cryoglobulins (P = .006) and circulating B-cell clones (P = .004), and had more frequently relapses of MCV (18% vs 3%, P = .028) and need for rituximab therapy (P = .01). Although largely inferior on an intention-to-treat basis, IFN may be superior to DAAs on clinico-immunological outcomes possibly owing to its antiproliferative activity.
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Affiliation(s)
- Stefania Colantuono
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ramona Marrapodi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Martina Del Padre
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Collalti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giulia Garzi
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Massimo Fiorilli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Basili
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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14
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Gioia S, De Santis E, Cerbelli B, Nardelli S, Ridola L, De Santis A, d'Amati G, Riggio O. Small hepatic veins Budd-Chiari syndrome and paroxysmal nocturnal hemoglobinuria - The association of two rare entities: a case report. Pathologica 2020; 112:102-104. [PMID: 32760053 PMCID: PMC7931566 DOI: 10.32074/1591-951x-4-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/20/2020] [Indexed: 12/02/2022] Open
Abstract
Small hepatic veins Budd-Chiari syndrome is a rare disorder characterized by hepatic venous outflow obstruction limited to the small intrahepatic veins, with normal appearance of the large hepatic veins at imaging. In this case only a liver biopsy can demonstrate the presence of a small vessels outflow block. Paroxysmal nocturnal haemoglobinuria (PNH) is one of the most severe acquired thrombophilic state and represents one of the main aetiological factors of Budd-Chiari syndrome. In patient affected by PNH with liver impairment and/or ascites, Budd-Chiari syndrome must be always taken into consideration and, if necessary, a liver biopsy performed to exclude the small hepatic veins involvement. We report a case of small hepatic veins Budd–Chiari syndrome secondary to paroxysmal nocturnal haemoglobinuria.
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Affiliation(s)
- Stefania Gioia
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | - Emanuela De Santis
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | - Bruna Cerbelli
- Department of Radiological, Oncological, and Pathological Sciences, "Sapienza" University of Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | - Adriano De Santis
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
| | - Giulia d'Amati
- Department of Radiological, Oncological, and Pathological Sciences, "Sapienza" University of Rome, Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, "Sapienza" University of Rome, Italy
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15
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Lionetti R, Piccolo P, Lenci I, Siciliano M, Visco-Comandini U, De Santis A, Pompili M, Milana M, Taibi C, Dell'Isola S, Montalbano M, Mastroianni C, Begini P, Garbuglia AR, Angelico M, D'Offizi G. Daclatasvir, sofosbuvir with or without ribavirin for 24 weeks in hepatitis C genotype 3 cirrhosis: A real-life study. Ann Hepatol 2020; 18:434-438. [PMID: 31023614 DOI: 10.1016/j.aohep.2018.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 09/02/2018] [Accepted: 09/05/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Cirrhotic patients with hepatitis C virus genotype 3 infection show unsatisfactory outcomes after 12 weeks' treatment with direct antiviral agents. The National Italian Drug Agency allows 24 weeks of therapy in difficult-to-treat patients, including genotype 3 cirrhotics. Aim of this study was to evaluate efficacy and safety of a 24-week course of sofosbuvir plus daclatasvir±ribavirin in this population. MATERIALS AND METHODS 106 consecutive cirrhotics (70.8% males, mean age 55.3±7.6 years) in 8 tertiary hepatology centers received sofosbuvir plus daclatasvir for 24 weeks. Ribavirin was administered in 85 (80.2%) based expected tolerability, at a mean dose of 964±202mg/day. Baseline Child-Pugh class was A 91.5%, B 6.6%, C 1.9%; mean baseline MELD was 8.5±2.7. RESULTS All patients completed 12-week follow-up post-treatment, and 104 (98.1%) obtained sustained virological response (100% in ribavirin -treated patients vs. 90.4% without ribavirin; p=0.04). No worsening in renal and liver function was observed, no serious adverse events occurred. Two virological failures showed resistance associated variants (Y93H and S282T). CONCLUSION An extended 24-week treatment with sofosbuvir plus daclatasvir+ribavirin obtained 100% efficacy in genotype 3 hepatitis C cirrhosis, with very limited side effects. The role of ribavirin seems crucial in this setting and should be administered if clinically feasible.
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Affiliation(s)
- Raffaella Lionetti
- Liver and Infectious Diseases, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy.
| | - Paola Piccolo
- Internal Medicine Unit, Fatebenefratelli Hospital Isola Tiberina, Rome, Italy; Liver Unit, Tor Vergata University Hospital, Rome, Italy
| | - Ilaria Lenci
- Liver Unit, Tor Vergata University Hospital, Rome, Italy
| | - Massimo Siciliano
- Gastroenterology and Liver Unit, Policlinico Gemelli, Catholic University, Rome, Italy
| | - Ubaldo Visco-Comandini
- Liver and Infectious Diseases, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy
| | - Adriano De Santis
- Gastroenterology and Liver Unit, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Maurizio Pompili
- Gastroenterology and Liver Unit, Policlinico Gemelli, Catholic University, Rome, Italy
| | - Martina Milana
- Liver Unit, Tor Vergata University Hospital, Rome, Italy
| | - Chiara Taibi
- Liver and Infectious Diseases, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy
| | - Serena Dell'Isola
- Medicina Protetta-Infectious Diseases, Belcolle Hospital, Viterbo, Italy
| | - Marzia Montalbano
- Liver and Infectious Diseases, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy
| | - Claudio Mastroianni
- Infectious Diseases, Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Paola Begini
- Liver Unit, Sant'Andrea University Hospital, Rome, Italy
| | - Anna Rosa Garbuglia
- Laboratory of Virology, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy
| | - Mario Angelico
- Liver Unit, Tor Vergata University Hospital, Rome, Italy
| | - Gianpiero D'Offizi
- Liver and Infectious Diseases, Lazzaro Spallanzani National Institute for Infectious Disease, Rome, Italy
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Ferri F, Mischitelli M, Tozzi G, Messina E, Mignini I, Mazzuca S, Pellone M, Parisse S, Marrapodi R, Visentini M, Baratta F, Del Ben M, Pastori D, Perciballi R, Attilia ML, Carbone M, De Santis A, Violi F, Angelico F, Corradini SG. Correction to: Reduced Lysosomal Acid Lipase Activity in Blood and Platelets Is Associated With Nonalcoholic Fatty Liver Disease. Clin Transl Gastroenterol 2020; 11:e00171. [PMID: 32251015 PMCID: PMC7263662 DOI: 10.14309/ctg.0000000000000171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
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17
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Visentini M, Del Padre M, Colantuono S, Yang B, Minafò YA, Antonini S, Carnovale M, De Santis A, Pulsoni A, De Sanctis GM, Gragnani L, Zignego AL, Fiorilli M, Casato M. Long-lasting persistence of large B-cell clones in hepatitis C virus-cured patients with complete response of mixed cryoglobulinaemia vasculitis. Liver Int 2019; 39:628-632. [PMID: 30690862 DOI: 10.1111/liv.14053] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/18/2018] [Accepted: 01/15/2019] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Hepatitis C virus (HCV)-related mixed cryoglobulinaemia vasculitis (MCV) is characterized by the expansion of rheumatoid factor-producing B-cell clones. The aim of this study was to assess whether B-cell clones may persist in these patients after the clearance of the virus with antiviral therapy, and whether their persistence influences clinical outcomes. METHODS Forty-five HCV-cured MCV patients were followed up for a median of 18.5 (range 9-38) months after the clearance of HCV. Circulating B-cell clones were detected using flow cytometry either by the skewing of kappa/lambda ratio or by the expression of a VH 1-69-encoded idiotype. RESULTS The clinical response of vasculitis was 78% complete, 18% partial and 4% null. However, cryoglobulins remained detectable in 42% of patients for more than 12 months. Circulating B-cell clones were detected in 18 of 45 patients, and in 17 of them persisted through the follow-up; nine of the latter patients cleared cryoglobulins and had complete response of vasculitis. Several months later, two of these patients had relapse of MCV. CONCLUSIONS B-cell clones persist in MCV patients long after HCV infection has been cleared but halt the production of pathogenic antibody. These 'dormant' cells may be reactivated by events that perturb B-cell homeostasis and can give rise to the relapse of cryoglobulinaemic vasculitis.
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Affiliation(s)
- Marcella Visentini
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.,Laboratory affiliated to Istituto Pasteur Italia-Fondazione Cenci Bolognetti, Sapienza University of Rome, Rome, Italy
| | - Martina Del Padre
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefania Colantuono
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Baoran Yang
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Ylenia Aura Minafò
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Antonini
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Myriam Carnovale
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Adriano De Santis
- Division of Gastroenterology and Hepatology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pulsoni
- Division of Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Laura Gragnani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), University of Florence, Florence, Italy
| | - Anna Linda Zignego
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), University of Florence, Florence, Italy
| | - Massimo Fiorilli
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Division of Clinical Immunology, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
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18
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Mancina RM, Ferri F, Farcomeni A, Molinaro A, Maffongelli A, Mischitelli M, Poli E, Parlati L, Burza MA, De Santis A, Attilia F, Rotondo C, Rando MM, Attilia ML, Ceccanti M, Ginanni Corradini S. A two gene-based risk score predicts alcoholic cirrhosis development in males with at-risk alcohol consumption. Appl Clin Genet 2019; 12:1-10. [PMID: 30666147 PMCID: PMC6330982 DOI: 10.2147/tacg.s187922] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Alcoholic cirrhosis represents 1% of all cause-of-deaths worldwide. Its incidence is higher in males and results from the combination of environmental and genetic factors. Among all the genetic determinants of alcoholic cirrhosis, the patatin-like phospholipase domain protein 3 (PNPLA3) rs738409 represents the most widely validated determinant. Recent cross-sectional studies on alcohol abusers identified transmembrane-6 superfamily member 2 (TM6SF2) rs58542926, membrane bound O-acyltransferase domain containing 7 (MBOAT7) rs641738, and cluster of differentiation 14 (CD14) rs2569190 as new genetic risk factors for alcoholic cirrhosis. We aimed to develop a gene-based risk score to predict the incidence of alcoholic cirrhosis in males with at-risk alcohol consumption. Materials and methods A total of 416 male at-risk alcohol drinkers were retrospectively examined. The association between alcoholic cirrhosis incidence and PNPLA3, CD14, TM6SF2, and MBOAT7 variants was tested. Age at onset of at-risk alcohol consumption, age, and body mass index (BMI) were included as covariates to determine the prediction score for alcoholic cirrhosis incidence by evaluating time-dependent receiver operating characteristic curves. Results We found that PNPLA3, CD14, and TM6SF2 were associated with alcoholic cirrhosis prevalence. PNPLA3 and CD14 were also associated with its incidence. The best predictive score formula was (age at onset of at-risk alcohol consumption × 0.1) + (number of CD14 allele T) + (number of PNPLA3 allele M) + (BMI × 0.1). A threshold of 7.27 was identified as cutoff for the predictive risk of alcoholic cirrhosis development in 36 years from the onset of at-risk alcohol consumption with 70.1% sensitivity and 78.7% specificity. Conclusion We developed the first score for alcoholic cirrhosis prediction that combines clinical and genetic factors.
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Affiliation(s)
- Rosellina Margherita Mancina
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at the University of Gothenburg, Wallenberg Laboratory, Göteborg, Sweden,
| | - Flaminia Ferri
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Antonio Molinaro
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at the University of Gothenburg, Wallenberg Laboratory, Göteborg, Sweden,
| | - Angela Maffongelli
- Department of General Surgery, Urgency and Organ Transplantation, University Hospital "Paolo Giaccone", University of Palermo, Palermo, Italy
| | - Monica Mischitelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Edoardo Poli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Lucia Parlati
- Hepatology Department, Université Paris Descartes, Cochin Hospital, APHP, Paris, France
| | - Maria Antonella Burza
- Department of Medicine, Division of Gastroenterology and Hepatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Adriano De Santis
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Fabio Attilia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Claudia Rotondo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Maria Margherita Rando
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Maria Luisa Attilia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
| | - Mauro Ceccanti
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy,
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19
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Masetti C, Lionetti R, Lupo M, Siciliano M, Giannelli V, Ponziani FR, Teti E, Dell'Unto C, Francioso S, Brega A, Montalbano M, Visco-Comandini U, Taibi C, Galati G, Vespasiani Gentilucci U, Picardi A, Andreoni M, Pompili M, Pellicelli AM, D'Offizi G, Gasbarrini A, De Santis A, Angelico M. Lack of reduction in serum alpha-fetoprotein during treatment with direct antiviral agents predicts hepatocellular carcinoma development in a large cohort of patients with hepatitis C virus-related cirrhosis. J Viral Hepat 2018; 25:1493-1500. [PMID: 30112854 DOI: 10.1111/jvh.12982] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/07/2018] [Accepted: 06/23/2018] [Indexed: 12/22/2022]
Abstract
Risk of hepatocellular carcinoma (HCC) in hepatitis C virus cirrhotic patients treated with direct-acting antiviral agents (DAA) is still debating. We investigated it in a large cohort. The cohort comprised 1045 cirrhotic patients who completed treatment with DAA, with a median follow-up of 17.3 months after end of treatment (EOT), including 943 patients without history of HCC and 102 previously treated for HCC. The majority were men (59.9%), with compensated cirrhosis (88.8%), genotype 1b (44.7%). Univariate, multivariate analysis and Kaplan-Meier curves were performed to detect predictors of HCC in patients with and without reduction in alpha-fetoprotein (AFP) during treatment. SVR12 was 95.6%. HCC developed in 95 (9.9%), including 54 of 943 (5.7%) occurrent and 41 of 102 (39%) recurrent tumours. De novo were more often unifocal (P = 0.01) and curable (P = 0.03). AFP decreased from 16.1 ± 36.2 mg/dL (baseline) to 11.4 ± 55 mg/dL (EOT). At univariate analysis, predictors were a previous HCC, older age, higher model for end-stage liver disease, prolonged INR, lower platelets, baseline and EOT AFP, virological failure and no reduction in AFP during treatment. Kaplan-Meier curves showed lower incidence of HCC in patients showing any reduction in AFP (P = 0.001). Those with AFP <6 ng/mL had the lowest risk (P = 0.0002). At logistic regression, platelets (P = 0.009, OR 0.99 CI: 0.99-1.00), previous HCC (P < 0.000 01, OR: 10.76, 95% CI: 5.89-19.34) and no reduction in AFP during treatment (P = 0.0005, OR: 2.98, CI: 1.60-5.54) were independent predictors of HCC. In conclusion, risk of HCC after DAA treatment remains substantial. It is higher among patients with previous HCC, low platelets and without reduction in AFP during treatment.
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Affiliation(s)
- Chiara Masetti
- Liver and Transplant Unit, Tor Vergata University Hospital, Rome, Italy
| | - Raffaella Lionetti
- Infectious Diseases-Hepatology, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | - Marinella Lupo
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | | | - Valerio Giannelli
- Liver Disease Unit, Department of Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Elisabetta Teti
- Department of Infectious Disease, Tor Vergata University Hospital, Rome, Italy
| | - Chiara Dell'Unto
- Internal Medicine and Hepatology Unit, University Campus Bio-Medico, Rome, Italy
| | - Simona Francioso
- Liver and Transplant Unit, Tor Vergata University Hospital, Rome, Italy
| | - Arianna Brega
- Liver and Transplant Unit, Tor Vergata University Hospital, Rome, Italy
| | - Marzia Montalbano
- Infectious Diseases-Hepatology, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | - Ubaldo Visco-Comandini
- Infectious Diseases-Hepatology, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | - Chiara Taibi
- Infectious Diseases-Hepatology, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | - Giovanni Galati
- Internal Medicine and Hepatology Unit, University Campus Bio-Medico, Rome, Italy
| | | | - Antonio Picardi
- Internal Medicine and Hepatology Unit, University Campus Bio-Medico, Rome, Italy
| | - Massimo Andreoni
- Department of Infectious Disease, Tor Vergata University Hospital, Rome, Italy
| | - Maurizio Pompili
- Internal Medicine, Gastroenterology and Hepatology, A. Gemelli Hospital, Rome, Italy
| | - Adriano M Pellicelli
- Liver Disease Unit, Department of Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Gianpiero D'Offizi
- Infectious Diseases-Hepatology, National Institute for Infectious Diseases Spallanzani, Rome, Italy
| | | | - Adriano De Santis
- Department of Clinical Medicine, Gastroenterology Unit, Sapienza University of Rome, Rome, Italy
| | - Mario Angelico
- Liver and Transplant Unit, Tor Vergata University Hospital, Rome, Italy
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Lattanzi B, Baroncelli S, De Santis A, Galluzzo CM, Mennini G, Michelini Z, Lupo M, Ginanni Corradini S, Rossi M, Palmisano L, Merli M. Microbial translocation and T cell activation are modified by direct-acting antiviral therapy in HCV-infected patients. Aliment Pharmacol Ther 2018; 48:1146-1155. [PMID: 30294870 DOI: 10.1111/apt.14994] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/03/2018] [Accepted: 08/30/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Microbial translocation from the gut lumen has been involved in the pathogenesis of liver damage in hepatitis C virus (HCV) infection. AIM To investigate the impact of direct-acting antiviral treatment on microbial translocation and T-cell activation, in patients with hepatitis C-related liver disease. METHODS We enrolled two groups of HCV-infected patients undergoing direct-acting antiviral treatment: patients with fibrosis ≥F3 according to Metavir (Group ≥F3); patients with hepatitis C recurrence after liver transplantation and Metavir ≥F2 (Group Liver Transplantation + ≥F2). All patients were treated with direct-acting antivirals based on ongoing guidelines. Surrogate biomarkers of microbial translocation (plasma concentrations of soluble-CD14, lipopolysaccharide-binding protein and intestinal fatty acid-binding protein) were evaluated at baseline, at first month, at the end of treatment and 3 months later. T-cell activation was measured by expression of CD38+ HLA-DR at the same time points, only in Group ≥F3. RESULTS There were 32 patients in Group ≥F3 and 13 in Group LT + ≥F2. At baseline, levels of soluble-CD14 and lipopolysaccharide-binding protein were significantly higher in both groups vs healthy controls. Baseline soluble-CD14 correlated with glutamic-oxalacetic transaminase (r = 0.384, P = 0.009) and glutamic-pyruvic transaminase (r = 0.293, P = 0.05). A significant decrease in plasma levels of surrogate microbial translocation biomarkers was observed during and after treatment in the two groups although values were not normalised. In Group ≥F3, CD38+ HLADR+ T-cell expression was significantly decreased by direct-acting antiviral treatment. Relapsers (9%) showed higher soluble-CD14 levels at baseline. CONCLUSION Surrogate microbial translocation markers and T cell activation are increased in HCV-infected patients with liver fibrosis and decrease during direct-acting antiviral treatment.
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Affiliation(s)
- Barbara Lattanzi
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Adriano De Santis
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Gianluca Mennini
- Hepato-biliopancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Zuleika Michelini
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marinella Lupo
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Stefano Ginanni Corradini
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Massimo Rossi
- Hepato-biliopancreatic and Liver Transplant Unit, Department of Surgery, Sapienza University of Rome, Rome, Italy
| | - Lucia Palmisano
- National Center for Preclinical and Clinical Drug Research and Evaluation, Istituto Superiore di Sanità, Rome, Italy
| | - Manuela Merli
- Division of Gastroenterology, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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Biolato M, Gallusi G, Iavarone M, Cabibbo G, Racco S, De Santis A, Corte CD, Maida M, Attili AF, Sangiovanni A, Cammà C, La Torre G, Gasbarrini A, Grieco A. Prognostic ability of BCLC-B Subclassification in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization. Ann Hepatol 2018; 17:110-118. [PMID: 29311396 DOI: 10.5604/01.3001.0010.7542] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
UNLABELLED Prognostic ability of BCLC-B Subclassification in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization Background and aims. A subclassification system for intermediate hepatocellular carcinoma (HCC) was recently proposed to optimize treatment allocation. The aim of this study was to assess the prognostic ability of that substaging proposal. PATIENTS AND METHODS This is a retrospective multicenter cohort study including patients with intermediate HCC treated with transarterial chemoembolization (TACE). Predictors of survival were identified using the Cox proportional regression model. RESULTS 289 Barcelona Clinic Liver Cancer (BCLC) B patients were included. Median overall survival of the whole cohort was 23 months (C.I. 95% 20.2- 25.8). Child A status (H.R. 1.35, C.I. 95% 1.02-1.78) and tumour burden beyond the up-to-seven criterion (H.R. 1.39, C.I. 95% 1.07- 1.80) were independent prognostic factors for overall survival on multivariate analysis. Analysis of the substages showed that median survival was 33.0 months for B1 stage (n = 81), 20.8 months for B2 stage (n = 106), 16.1 months for B3 stage (n = 24), 22.2 months for B4 stage (n = 42) and 15.0 months for quasi-C stage (n = 36). Regarding the discriminatory ability of the substaging proposal, the log rank test showed a significant survival difference for B1vs. B4 (p = 0.003) and B1 vs. Quasi-C (p = 0.039) and a trend for B1 vs. B2 (p = 0.05) and B1 vs. B3 (p = 0.05). CONCLUSIONS Apart from substage B1, BCLC-B subclassification does not discriminate perfectly patients treated with TACE. Also some patients in substage B4 can benefit from TACE.
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Affiliation(s)
- Marco Biolato
- Department of Internal Medicine, Fondazione Policlinico Gemelli Catholic University of the Sacred Heart, Rome, Italy
| | - Giulia Gallusi
- Division of Gastroenterology, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Massimo Iavarone
- UO Gastroenterologia ed Epatologia, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Cabibbo
- Section of Gastroenterology, DIBIMIS, University of Palermo, Palermo, Italy
| | - Simona Racco
- Department of Internal Medicine, Fondazione Policlinico Gemelli Catholic University of the Sacred Heart, Rome, Italy
| | - Adriano De Santis
- Division of Gastroenterology, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Cristina Della Corte
- UO Gastroenterologia ed Epatologia, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marcello Maida
- Section of Gastroenterology, DIBIMIS, University of Palermo, Palermo, Italy
| | - Adolfo Francesco Attili
- Division of Gastroenterology, Department of Clinical Medicine, La Sapienza University of Rome, Rome, Italy
| | - Angelo Sangiovanni
- UO Gastroenterologia ed Epatologia, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Calogero Cammà
- Section of Gastroenterology, DIBIMIS, University of Palermo, Palermo, Italy
| | - Giuseppe La Torre
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Antonio Gasbarrini
- Department of Internal Medicine, Fondazione Policlinico Gemelli Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Grieco
- Department of Internal Medicine, Fondazione Policlinico Gemelli Catholic University of the Sacred Heart, Rome, Italy
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22
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Lanini S, Scognamiglio P, Mecozzi A, Lombardozzi L, Vullo V, Angelico M, Gasbarrini A, Taliani G, Attili AF, Perno CF, De Santis A, Puro V, Cerqua F, D’Offizi G, Pellicelli A, Armignacco O, Mennini FS, Siciliano M, Girardi E, Panella V, Ippolito G. Impact of new DAA therapy on real clinical practice: a multicenter region-wide cohort study. BMC Infect Dis 2018; 18:223. [PMID: 29769038 PMCID: PMC5956792 DOI: 10.1186/s12879-018-3125-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Management of chronic hepatitis C (CHC) has significantly accelerated in the last few years. Currently, second generation direct acting antivirals (DAAs) promise clearance of infection in most of patients. Here we present the results of the first analysis carried out on data of Lazio clinical network for DAAs. METHODS The study was designed as a multicenter cohort: a) to assess the evolution of treatment during the first 24 months of the activity of the Clinical Network; b) to report overall efficacy of treatments; c) to analyze potential factors associated with lack of virological response at 12 weeks after therapy (SVR12); d) to evaluate the variation of ALT at baseline and 12 weeks after therapy in those who achieved SVR12 in comparison to those who did not. Analyses of efficacy were carried out with multilevel mixed effect logistic regression model. ALT temporal variation was assessed by mixed effect model mixed models with random intercept at patient's level and random slope at the level of the time; i.e. either before or after therapy. RESULTS Between 30 December 2014 and 31 December 2016 5279 patients started a DAA treatment; of those, 5127 (in 14 clinical centers) had completed the 12-week follow-up. Overall proportion of SVR12 was 93.41% (N = 4780) with no heterogeneity between the 14 clinical centers. Interruption as the consequence of severe side effect was very low (only 23 patients). Unadjusted analysis indicates that proportion of SVR12 significantly changes according to patient's baseline characteristics, however after adjusting for potential confounders only adherence to current guidelines, stage of liver diseases, gender, transplant and HIV status were independently associated with the response to therapy. Analysis of ALT temporal variation showed that ALT level normalized in most, but not, all patients who achieved SVR12. CONCLUSION Our study confirmed the extraordinary efficacy of DAAs outside clinical trials. The advantage of DAAs was particularly significant for those patients who were previously considered as difficult-to-treat and did not have treatment options before DAAs era. Intervention based on network of select centers and prioritization of patients according to diseases severity was successful. Further studies are needed to establish whether clearance of HCV after DAAs therapy can arrest or even revert liver fibrosis in non-cirrhotic patients and/or improve life quality and expectancy in those who achieve SVR12 with cirrhosis.
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Affiliation(s)
- Simone Lanini
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
- Servizio Regionale per la Sorveglianza delle Malattie infettive (SeRESMI), Rome, Italy
| | - Paola Scognamiglio
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
- Servizio Regionale per la Sorveglianza delle Malattie infettive (SeRESMI), Rome, Italy
| | - Alessandra Mecozzi
- Regione Lazio Direzione Regionale Salute e Politiche Sociali, Rome, Italy
| | | | - Vincenzo Vullo
- Dipartimento di Sanità Pubblica e Malattie Infettive Sapienza Università di Roma, Rome, Italy
| | - Mario Angelico
- Unità di Epatologia e Trapianti, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Antonio Gasbarrini
- Gastroenterologia, Fondazione Policlinico Gemelli, Universita’ Cattolica del Sacro Cuore, Rome, Italy
| | - Gloria Taliani
- Dipartimento di Medicina Clinica Sapienza, Università di Roma, Rome, Italy
| | | | - Carlo Federico Perno
- Department of Experimental Medicine and Surgery, University of Roma Tor Vergata, Rome, Italy
| | - Adriano De Santis
- Dipartimento di Medicina Clinica Sapienza, Università di Roma, Rome, Italy
| | - Vincenzo Puro
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
- Servizio Regionale per la Sorveglianza delle Malattie infettive (SeRESMI), Rome, Italy
| | | | - Gianpiero D’Offizi
- UOC Malattie Infettive Epatologia Dipartimento Interaziendale Trapianti National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Adriano Pellicelli
- UOC Malattie del Fegato Dipartimento Interaziendale Trapianti AO San Camillo Forlanini Roma, Rome, Italy
| | | | - Francesco Saverio Mennini
- EEHTA CEIS, Università di Roma “Tor Vergata” e Institute of Leadership and Management in Health, Kingston University, London, UK
| | - Massimo Siciliano
- Gastroenterologia, Fondazione Policlinico Gemelli, Universita’ Cattolica del Sacro Cuore, Rome, Italy
| | - Enrico Girardi
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
| | - Vincenzo Panella
- Servizio Regionale per la Sorveglianza delle Malattie infettive (SeRESMI), Rome, Italy
| | - Giuseppe Ippolito
- National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, Rome, Italy
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De Santis A, Nardelli S, Bassanelli C, Lupo M, Iegri C, Di Ciesco CA, Forlino M, Farcomeni A, Riggio O. Modification of splenic stiffness on acoustic radiation force impulse parallels the variation of portal pressure induced by transjugular intrahepatic portosystemic shunt. J Gastroenterol Hepatol 2018; 33:704-709. [PMID: 28753738 DOI: 10.1111/jgh.13907] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 06/25/2017] [Accepted: 07/17/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIM Spleen and liver stiffness (LS) measured by acoustic radiation force impulse (ARFI) imaging has been shown to be useful in identifying patients with portal hypertension. The study aims to establish if the modification of portal pressure induced by a transjugular intrahepatic portosystemic shunt (TIPS) parallels the modification of spleen or LS measured by ARFI in order to understand if ARFI may be used to monitor the modification of portal pressure in patients with cirrhosis. METHODS Thirty-eight patients with severe portal hypertension underwent LS and spleen stiffness (SS) before TIPS and 1 week after TIPS. Portal atrial gradient (PAG) was measured before and after the shunt opening. RESULTS Portal atrial gradient decreased significantly from 19.5 to 6 mmHg (P < 0.001). SS decreased significantly after TIPS (pre-TIPS 3.7 m/s vs post-TIPS 3. 1 m/s; P < 0.001), and LS was also significantly modified by TIPS (pre-TIPS 2.8 m/s vs post-TIPS 2.4 m/s; P = 0.003). PAG and SS values measured before and after TIPS were significantly correlated (r = 0.56; P < 0.001); on the other hand, PAG and LS were not (r = 0.19; P = 0.27). Two patients developed a persistent hepatic encephalopathy refractory to medical treatment and were submitted to the reduction of the stent diameter. The modification of SS was parallel to the modification of PAG. CONCLUSION Spleen stiffness is superior to LS in detecting the modification of portal pressure induced by TIPS. This makes SS a potential non-invasive method to monitor the modification of portal hypertension. Further investigations are needed to establish applicability and clinical utility of this promising tool in the treatment of portal hypertension.
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Affiliation(s)
- Adriano De Santis
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Chiara Bassanelli
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Marinella Lupo
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Claudia Iegri
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Carmela Anna Di Ciesco
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Mariana Forlino
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
| | - Alessio Farcomeni
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Gastroenterology Unit and Center for the study of Portal Hypertension, Sapienza University of Rome, Rome, Italy
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Gragnani L, Visentini M, Fognani E, Urraro T, De Santis A, Petraccia L, Perez M, Ceccotti G, Colantuono S, Mitrevski M, Stasi C, Del Padre M, Monti M, Gianni E, Pulsoni A, Fiorilli M, Casato M, Zignego AL. Prospective study of guideline-tailored therapy with direct-acting antivirals for hepatitis C virus-associated mixed cryoglobulinemia. Hepatology 2016; 64:1473-1482. [PMID: 27483451 DOI: 10.1002/hep.28753] [Citation(s) in RCA: 154] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 07/15/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023]
Abstract
UNLABELLED Hepatitis C virus (HCV)-associated mixed cryoglobulinemia (MC) vasculitis commonly regresses upon virus eradication, but conventional therapy with pegylated interferon and ribavirin yields approximately 40% sustained virologic responses (SVR). We prospectively evaluated the efficacy and safety of sofosbuvir-based direct-acting antiviral therapy, individually tailored according to the latest guidelines, in a cohort of 44 consecutive patients with HCV-associated MC. In two patients MC had evolved into an indolent lymphoma with monoclonal B-cell lymphocytosis. All patients had negative HCV viremia at week 12 (SVR12) and at week 24 (SVR24) posttreatment, at which time all had a clinical response of vasculitis. The mean (±standard deviation) Birmingham Vasculitis Activity Score decreased from 5.41 (±3.53) at baseline to 2.35 (±2.25) (P < 0.001) at week 4 on treatment to 1.39 (±1.48) (P < 0.001) at SVR12 and to 1.27 (±1.68) (P < 0.001) at SVR24. The mean cryocrit value fell from 7.2 (±15.4)% at baseline to 2.9 (±7.4)% (P < 0.01) at SVR12 and to 1.8 (±5.1)% (P < 0.001) at SVR24. Intriguingly, in the 2 patients with MC and lymphoma there was a partial clinical response of vasculitis and ∼50% decrease of cryocrit, although none experienced a significant decrease of monoclonal B-cell lymphocytosis. Adverse events occurred in 59% of patients and were generally mild, with the exception of 1 patient with ribavirin-related anemia requiring blood transfusion. CONCLUSION Interferon-free, guideline-tailored therapy with direct-acting antivirals is highly effective and safe for HCV-associated MC patients; the overall 100% rate of clinical response of vasculitis, on an intention-to-treat basis, opens the perspective for curing the large majority of these so far difficult-to-treat patients. (Hepatology 2016;64:1473-1482).
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Affiliation(s)
- Laura Gragnani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marcella Visentini
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Elisa Fognani
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Teresa Urraro
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Adriano De Santis
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Luisa Petraccia
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Marie Perez
- Istituto Dermopatico Dell'Immacolata IRCCS, Rome, Italy
| | - Giorgia Ceccotti
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | | | - Milica Mitrevski
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Cristina Stasi
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Martina Del Padre
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Monica Monti
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Elena Gianni
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandro Pulsoni
- Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Italy
| | - Massimo Fiorilli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Milvia Casato
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Anna Linda Zignego
- Interdepartmental Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
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Abstract
The management of patients with refractory GERD (rGERD) is a major clinical challenge for gastroenterologists. In up to 30% of patients with typical GERD symptoms (heartburn and/or regurgitation), acid-suppressive therapy does not provide clinical benefit. In this Review, we discuss the current management algorithm for GERD and the features and management of patients who do not respond to treatment (such as those individuals with an incorrect diagnosis of GERD, inadequate PPI intake, persisting acid reflux and persisting weakly acidic reflux). Symptom response to existing surgical techniques, novel antireflux procedures, and the value of add-on medical therapies (including prokinetics and reflux inhibitors) for rGERD symptoms are discussed. Pharmaceutical agents targeting oesophageal sensitivity, a condition that can contribute to symptom generation in rGERD, are also discussed. Finally, on the basis of available published data and our expert opinion, we present an outline of a current, usable algorithm for management of patients with rGERD that considers the timing and diagnostic use of pH-impedance monitoring on or off PPI, additional diagnostic tests, the clinical use of baclofen and the use of add-on neuromodulators (tricyclic agents and selective serotonin reuptake inhibitors).
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Affiliation(s)
- Emidio Scarpellini
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Division Gastroenterology, Sapienza University of Rome, Viale del Policlinico 155, 00100, Rome, Italy
| | - Daphne Ang
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Ans Pauwels
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Adriano De Santis
- Division of Gastroenterology, Changi General Hospital, 2 Simei Street 3, Singapore 529889
| | - Tim Vanuytsel
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jan Tack
- Translational Research in Gastrointestinal Disorders (TARGID), University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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26
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Visentini M, Pascolini S, Mitrevski M, Marrapodi R, Del Padre M, Todi L, Camponeschi A, Axiotis E, Carlesimo M, De Santis A, Fiorilli M, Casato M. Hepatitis B virus causes mixed cryoglobulinaemia by driving clonal expansion of innate B-cells producing a VH1-69-encoded antibody. Clin Exp Rheumatol 2016; 34:S28-S32. [PMID: 26811981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 07/20/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES To investigate the expression of a VH1-69-encoded idiotype, and the phenotypic and functional features of monoclonal B-cells from patients with type II mixed cryoglobulinaemia (MC) secondary to chronic hepatitis B virus (HBV) infection. METHODS B-cell immunophenotype and expression of a VH1-69-encoded idiotype were investigated by flow cytometry. B-cell proliferative responses to stimuli were investigated by the CFSE dilution assay. RESULTS Two out of five patients with chronic HBV studied had massive monoclonal expansion of VH1-69-expressing B-cells. These cells had the peculiar CD21(low) phenotype and low responsiveness to stimuli typical of the VH1-69-expressing B-cells commonly expanded in MC secondary to hepatitis C virus (HCV) infection. In both patients, anti-HBV therapy led to the regression of MC and of VH1-69+ B-cell expansion. CONCLUSIONS VH1-69-encoded antibodies are known to preferentially recognise a variety of viral proteins including HCV E2, influenza A virus haemagglutinin and HIV gp41/gp120, and may serve as innate first line antiviral defense. Thus, like HCV, HBV may cause MC by protracted antigenic stimulation of VH1-69-expressing B-cells.
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Affiliation(s)
- Marcella Visentini
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy.
| | - Simona Pascolini
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Milica Mitrevski
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Ramona Marrapodi
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Martina Del Padre
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Laura Todi
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Alessandro Camponeschi
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Evangelos Axiotis
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Maurizio Carlesimo
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Adriano De Santis
- Division of Gastroenterology and Hepatology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Massimo Fiorilli
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
| | - Milvia Casato
- Division of Clinical Immunology, Department of Clinical Medicine, Sapienza University of Rome, Italy
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Scarpellini E, Forlino M, Lupo M, Rasetti C, Fava G, Abenavoli L, De Santis A. Gut Microbiota and Alcoholic Liver Disease. Rev Recent Clin Trials 2016; 11:213-219. [PMID: 27515958 DOI: 10.2174/1574887111666160810100538] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/04/2016] [Accepted: 02/08/2016] [Indexed: 06/06/2023]
Abstract
The gut-liver axis model has often explained liver disease physiopathology. Among the latter we can mention Non-Alcoholic Liver Steatosis (NAFLD), Liver Steatohepatitis (NASH), liver cirrhosis. In this frame an altered Intestinal Permeability (IP) is the gate for antigenic/toxic substances from gut lumen until target organs such as liver in NAFLD. Altered intestinal permeability was discovered almost forty years ago as consequence of acute and chronic alcohol ingestion. Alcohol Liver Disease (ALD) is a systemic pathology whose beginning and end belong to the intestine. Several recent evidences from the literature show how gut microbiota composition can be altered by alcohol, affects IP and can be modulated by several nonpharmacological and pharmacological agents, becoming the target for ALD treatment. In this review we describe the definition of ALD, gut microbiota composition in healthy and ALD, definition and role of IP in ALD physiopathology and emerging evidences on gut microbiota modulation in ALD treatment from preliminary clinical and non-clinical studies.
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Affiliation(s)
- Emidio Scarpellini
- Division of Gastroenterology, Umberto I University Hospital, 'Sapienza' University of Rome, Rome, Viale del Policlinico 155, Italy
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Scarpellini E, Ianiro G, Attili F, Bassanelli C, De Santis A, Gasbarrini A. The human gut microbiota and virome: Potential therapeutic implications. Dig Liver Dis 2015; 47:1007-12. [PMID: 26257129 PMCID: PMC7185617 DOI: 10.1016/j.dld.2015.07.008] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 07/06/2015] [Accepted: 07/13/2015] [Indexed: 02/07/2023]
Abstract
Human gut microbiota is a complex ecosystem with several functions integrated in the host organism (metabolic, immune, nutrients absorption, etc.). Human microbiota is composed by bacteria, yeasts, fungi and, last but not least, viruses, whose composition has not been completely described. According to previous evidence on pathogenic viruses, the human gut harbours plant-derived viruses, giant viruses and, only recently, abundant bacteriophages. New metagenomic methods have allowed to reconstitute entire viral genomes from the genetic material spread in the human gut, opening new perspectives on the understanding of the gut virome composition, the importance of gut microbiome, and potential clinical applications. This review reports the latest evidence on human gut "virome" composition and its function, possible future therapeutic applications in human health in the context of the gut microbiota, and attempts to clarify the role of the gut "virome" in the larger microbial ecosystem.
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Affiliation(s)
- Emidio Scarpellini
- Department of Pediatrics, Umberto I University Hospital, “Sapienza” University of Rome, Italy
| | - Gianluca Ianiro
- Division of Internal Medicine and Gastroenterology, Gemelli University Hospital, Catholic University of Sacred Heart, Italy
| | - Fabia Attili
- Division of Endoscopy, Gemelli University Hospital, Catholic University of Sacred Heart, Italy
| | - Chiara Bassanelli
- Gastroenterology Division, Umberto I University Hospital, “Sapienza” University of Rome, Italy
| | - Adriano De Santis
- Gastroenterology Division, Umberto I University Hospital, “Sapienza” University of Rome, Italy
| | - Antonio Gasbarrini
- Division of Internal Medicine and Gastroenterology, Gemelli University Hospital, Catholic University of Sacred Heart, Italy,Corresponding author at: Gastroenterology and Internal Medicine Division, Catholic University of Sacred Heart, Largo Gemelli 1, 00168 Rome, Italy. Tel.: +39 06 3015 6265; fax: +39 06 3015 6265.
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29
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De Santis A, Iegri C, Kondili L, Riggio O, Salvatori FM, Catalano C, Di Martino M, Bassanelli C, Lupo M, Lucatelli P, Attili AF. Hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt: a retrospective case-control study. Dig Liver Dis 2014; 46:726-30. [PMID: 24893685 DOI: 10.1016/j.dld.2014.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/19/2014] [Accepted: 04/25/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND An association between Transjugular Intrahepatic Porto-Systemic Shunt (TIPS) and the development of hepatocellular carcinoma in patients with cirrhosis has been suggested, but not confirmed. AIM To evaluate the potential role of TIPS in hepatocellular carcinoma development. METHODS We performed a retrospective case-control study among patients with cirrhosis; all cases had undergone TIPS placement. Cases and controls were followed as outpatients at a single liver care centre in the same timeframe. RESULTS Overall, 101 patients with cirrhosis (mean age 58 ± 9 years, 64.3% male) were included in each group. Median duration of follow-up was 56.7 months (range 8.2-174.5) for TIPS patients and 67.8 months (range 8.3-183.1) for controls (p=0.08). In both groups 94% of patients had Child-Pugh Class A or B cirrhosis. The cumulative incidence of hepatocellular carcinoma at 1, 3, 5, and 10 years was 2%, 7%, 18%, and 46% among TIPS patients, and 3%, 10%, 19%, and 39% among controls (log rank test p=0.19). Compared to controls, hepatocellular carcinoma nodules in TIPS patients were more frequently situated in the right lobe (p<0.05). CONCLUSIONS TIPS does not seem to increase the risk of hepatocellular carcinoma in patients with Child-Pugh Class A or B cirrhosis; for these patients ultrasound surveillance should not be modified.
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Affiliation(s)
- Adriano De Santis
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy.
| | - Claudia Iegri
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy
| | - Loreta Kondili
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy; Center for Immunobiologicals Research and Evaluation, Italian National Institute of Health, Rome, Italy
| | - Oliviero Riggio
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy
| | - Filippo Maria Salvatori
- Department of Radiological Sciences, Oncology and Anatomical Pathology, "Sapienza", University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological Sciences, Oncology and Anatomical Pathology, "Sapienza", University of Rome, Rome, Italy
| | - Michele Di Martino
- Department of Radiological Sciences, Oncology and Anatomical Pathology, "Sapienza", University of Rome, Rome, Italy
| | - Chiara Bassanelli
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy
| | - Marinella Lupo
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy
| | - Pierleone Lucatelli
- Department of Radiological Sciences, Oncology and Anatomical Pathology, "Sapienza", University of Rome, Rome, Italy
| | - Adolfo Francesco Attili
- Department of Clinical Medicine, Division of Gastroenterology, "Sapienza", University of Rome, Rome, Italy
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30
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Burza MA, Molinaro A, Attilia ML, Rotondo C, Attilia F, Ceccanti M, Ferri F, Maldarelli F, Maffongelli A, De Santis A, Attili AF, Romeo S, Ginanni Corradini S. PNPLA3 I148M (rs738409) genetic variant and age at onset of at-risk alcohol consumption are independent risk factors for alcoholic cirrhosis. Liver Int 2014; 34:514-20. [PMID: 24102786 PMCID: PMC4265268 DOI: 10.1111/liv.12310] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 08/10/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Environmental and genetic factors contribute to alcoholic cirrhosis onset. In particular, age at exposure to liver stressors has been shown to be important in progression to fibrosis in hepatitis C individuals. However, no definite data on the role of age at onset of at-risk alcohol consumption are available. Moreover, patatin-like phospholipase domain-containing protein 3 (PNPLA3) I148M (rs738409) variant has been associated with alcoholic cirrhosis, but only in cross-sectional studies. The aim of this study was to investigate the role of age at onset of at-risk alcohol consumption and PNPLA3 I148M variant on alcoholic cirrhosis incidence. METHODS A total of 384 at-risk alcohol drinkers were retrospectively examined. The association among age at onset of at-risk alcohol consumption, PNPLA3 I148M variant and cirrhosis incidence was tested. RESULTS A higher incidence of alcoholic cirrhosis was observed in individuals with an older (≥24 years) compared with a younger (<24) age at onset of at-risk alcohol consumption (P-value < 0.001). Moreover, PNPLA3 148M allele carriers showed an increased incidence of cirrhosis (P-value < 0.001). Both age at onset of at-risk alcohol consumption and PNPLA3 148M allele were independent risk factors for developing cirrhosis (H.R. (95% C.I.): 2.76 (2.18-3.50), P-value < 0.001; 1.53(1.07-2.19), P-value = 0.021 respectively). The 148M allele was associated with a two-fold increased risk of cirrhosis in individuals with a younger compared with an older age at onset of at-risk alcohol consumption (H.R. (95% C.I.): 3.03(1.53-6.00) vs. 1.61(1.09-2.38). CONCLUSIONS Age at onset of at-risk alcohol consumption and PNPLA3 I148M genetic variant are independently associated with alcoholic cirrhosis incidence.
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Affiliation(s)
- Maria Antonella Burza
- Institute of Medicine, Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of GothenburgGothenburg, Sweden,
* These authors have equally contributed to this study
| | - Antonio Molinaro
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy,
* These authors have equally contributed to this study
| | - Maria Luisa Attilia
- Department of Clinical Medicine, Alcohol Liver Disease Unit, Sapienza University of RomeRome, Italy
| | - Claudia Rotondo
- Department of Clinical Medicine, Alcohol Liver Disease Unit, Sapienza University of RomeRome, Italy
| | - Fabio Attilia
- Department of Clinical Medicine, Alcohol Liver Disease Unit, Sapienza University of RomeRome, Italy
| | - Mauro Ceccanti
- Department of Clinical Medicine, Alcohol Liver Disease Unit, Sapienza University of RomeRome, Italy
| | - Flaminia Ferri
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
| | - Federica Maldarelli
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
| | - Angela Maffongelli
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
| | - Adriano De Santis
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
| | - Adolfo Francesco Attili
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
| | - Stefano Romeo
- Institute of Medicine, Department of Molecular and Clinical Medicine, Wallenberg Laboratory, University of GothenburgGothenburg, Sweden,Department of Medical and Surgical Science, University Magna Graecia of Catanzaro, Clinical Nutrition UnitCatanzaro, Italy
| | - Stefano Ginanni Corradini
- Department of Clinical Medicine, Division of Gastroenterology, Sapienza University of RomeRome, Italy
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Cardinale V, De Filippis G, Corsi A, La Penna A, Rossi M, Catalano C, Bianco P, De Santis A, Alvaro D. An isolate alpha-fetoprotein producing gastric cancer liver metastasis emerged in a patient previously affected by radiation induced liver disease. World J Hepatol 2013; 5:398-403. [PMID: 23898374 PMCID: PMC3724969 DOI: 10.4254/wjh.v5.i7.398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/05/2011] [Accepted: 11/14/2012] [Indexed: 02/06/2023] Open
Abstract
We report a case of an isolated hepatic neoplasia which originated in a site of the liver previously affected by radiation induced liver disease (RILD) in a patient resected for gastric cancer and referred to us for high serum alpha-fetoprotein (AFP) levels. This case challenged us in distiguishing, even histologically, between primary liver cancer and AFP producing gastric cancer metastasis. Only a panel of immunohistochemical markers allowed the definitive diagnosis of liver metastasis of endodermal stem cell-derived and AFP producing gastric cancer. We discuss the criteria for a differential diagnosis, as well as the possible link between RILD and emergence of liver neoplasia.
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Affiliation(s)
- Vincenzo Cardinale
- Vincenzo Cardinale, Domenico Alvaro, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00185 Rome, Italy
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Di Martino M, De Filippis G, De Santis A, Geiger D, Del Monte M, Lombardo CV, Rossi M, Corradini SG, Mennini G, Catalano C. Hepatocellular carcinoma in cirrhotic patients: prospective comparison of US, CT and MR imaging. Eur Radiol 2012. [PMID: 23179521 DOI: 10.1007/s00330-012-2691-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To prospectively compare the diagnostic performance of ultrasound (US), multidetector computed tomography (MDCT) and contrast-enhanced magnetic resonance imaging (MRI) in cirrhotic patients who were candidates for liver transplantation. METHODS One hundred and forty consecutive patients with 163 hepatocellular carcinoma (HCC) nodules underwent US, MRI and MDCT. Diagnosis of HCC was based on pathological findings or substantial growth at 12-month follow-up. Four different image datasets were evaluated: US, MDCT, MRI unenhanced and dynamic phases, MRI unenhanced dynamic and hepatobiliary phase. Diagnostic accuracy, sensitivity, specificity, PPV and NPV, with corresponding 95 % confidence intervals, were determined. Statistical analysis was performed for all lesions and for three lesion subgroups (<1 cm, 1-2 cm, >2 cm). RESULTS Significantly higher diagnostic accuracy, sensitivity and NPV was achieved on dynamic + hepatobiliary phase MRI compared with US, MDCT and dynamic phase MRI alone. The specificity and PPV of US was significantly lower than that of MDCT, dynamic phase MRI and dynamic + hepatobiliary phase MRI. Similar results were obtained for all sub-group analyses, with particular benefit for the diagnosis of smaller lesions between 1 and 2 cm. CONCLUSIONS Dynamic + hepatobiliary phase MRI improved detection and characterisation of HCC in cirrhotic patients. The greatest benefit is for diagnosing lesions between 1 and 2 cm.
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Affiliation(s)
- Michele Di Martino
- Department of Radiological Sciences, Oncology and Anatomical Pathology, University of Rome "Sapienza", Viale Regina Elena 324, Rome 00161, Italy
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Corradini SG, Ferri F, Mordenti M, Iuliano L, Siciliano M, Burza MA, Sordi B, Caciotti B, Pacini M, Poli E, Santis AD, Roda A, Colliva C, Simoni P, Attili AF. Beneficial effect of sulphate-bicarbonate-calcium water on gallstone risk and weight control. World J Gastroenterol 2012; 18:930-7. [PMID: 22408352 PMCID: PMC3297052 DOI: 10.3748/wjg.v18.i9.930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 09/09/2011] [Accepted: 12/31/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of drinking sulphate-bicarbonate-calcium thermal water (TW) on risk factors for atherosclerosis and cholesterol gallstone disease.
METHODS: Postmenopausal women with functional dyspepsia and/or constipation underwent a 12 d cycle of thermal (n = 20) or tap (n = 20) water controlled drinking. Gallbladder fasting volume at ultrasound, blood vitamin E, oxysterols (7-β-hydroxycholesterol and 7-ketocholesterol), bile acid (BA), triglycerides, total/low density lipoprotein and high density lipoprotein cholesterol were measured at baseline and at the end of the study. Food consumption, stool frequency and body weight were recorded daily.
RESULTS: Blood lipids, oxysterols and vitamin E were not affected by either thermal or tap water consumption. Fasting gallbladder volume was significantly (P < 0.005) smaller at the end of the study than at baseline in the TW (15.7 ± 1.1 mL vs 20.1 ± 1.7 mL) but not in the tap water group (19.0 ± 1.4 mL vs 19.4 ± 1.5 mL). Total serum BA concentration was significantly (P < 0.05) higher at the end of the study than at baseline in the TW (5.83 ± 1.24 μmol vs 4.25 ± 1.00 μmol) but not in the tap water group (3.41 ± 0.46 μmol vs 2.91 ± 0.56 μmol). The increased BA concentration after TW consumption was mainly accounted for by glycochenodeoxycholic acid. The number of pasta (P < 0.001), meat (P < 0.001) and vegetable (P < 0.005) portions consumed during the study and of bowel movements per day (P < 0.05) were significantly higher in the TW than in the tap water group. Body weight did not change at the end of the study as compared to baseline in both groups.
CONCLUSION: Sulphate-bicarbonate-calcium water consumption has a positive effect on lithogenic risk and intestinal transit and allows maintenance of a stable body weight despite a high food intake.
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De Santis A, Moscatelli R, Catalano C, Iannetti A, Gigliotti F, Cristofari F, Trapani S, Attili AF. Systemic thrombolysis of portal vein thrombosis in cirrhotic patients: a pilot study. Dig Liver Dis 2010; 42:451-5. [PMID: 19819770 DOI: 10.1016/j.dld.2009.08.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 08/08/2009] [Accepted: 08/30/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Portal vein thrombosis is a frequent complication in liver cirrhosis. Encouraging reports of systemic thrombolysis in non-cirrhotic patients suffering from acute portal vein thrombosis led us to start a pilot study on the efficacy and safety of systemic low dose recombinant tissue plasminogen activator (Actilyse, Boheringer Ingelheim, Florence, Italy). PATIENTS Nine cirrhotic patients (6 males and 3 females) with recent portal vein thrombosis were enrolled. Exclusion criteria were portal cavernomatosis, recent (30 days) surgery, active bleeding, hepatocellular carcinoma and cancer in other sites. METHODS All cases were treated for a maximum of 7 days by continuous i.v. infusion of 0.25mg/kg/die of r-tPA plus subcutaneous low molecular weight heparin. Efficacy was evaluated by colour doppler sonography monitoring and confirmed by contrast enhanced computerized tomography. RESULTS The combined r-tPA/LMWH treatment was well tolerated without clinically significant side effects. Complete resolution of thrombosis occurred in 4 cases, partial regression in 4 and none in 1. Retreatment of a complete recurrence in 1 patient was successful. Variceal pressure dropped from 30.7+/-4.5 mmHg to 21.2+/-6.6 mmHg (p=0.012). CONCLUSIONS Our preliminary data demonstrate that thrombolytic treatment of recent portal vein thrombosis with i.v. r-tPA and LMWH in patients with cirrhosis appears to be safe and effective and can significantly reduce pressure in oesophageal varices.
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Affiliation(s)
- Adriano De Santis
- GI Unit, Department of Clinical Medicine, University of Rome La Sapienza, Rome, Italy.
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Piccolo P, Lenci I, Demelia L, Bandiera F, Piras MR, Antonucci G, Nosotti L, Mari T, De Santis A, Ponti ML, Sorbello O, Iacomi F, Angelico M. A randomized controlled trial of pegylated interferon-alpha2a plus adefovir dipivoxil for hepatitis B e antigen-negative chronic hepatitis B. Antivir Ther 2010; 14:1165-74. [PMID: 20032546 DOI: 10.3851/imp1466] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Pegylated interferon (PEG-IFN)-alpha monotherapy is the current standard of care for short-term antiviral treatment of hepatitis B e antigen (HBeAg)-negative chronic hepatitis B (CHB). We aimed to assess the safety and efficacy of PEG-IFN-alpha plus adefovir dipivoxil (ADV) versus PEG-IFN-alpha monotherapy for compensated HBeAg-negative CHB. METHODS A multicentre randomized controlled trial was performed in eight outpatient hepatology/infectious disease clinics in central Italy. A total of 60 patients (67% male and median age 48 years) with biopsy-proven HBeAg-negative compensated CHB (mean alanine aminotranferase [ALT] levels 3.3 +/-3x the upper normal limit and serum hepatitis B virus [HBV] DNA 5.8 +/-0.9 log(10) IU/ml) were randomized at baseline to receive PEG-IFN-alpha2a 180 microg/week plus ADV 10 mg/day or PEG-IFN-alpha2a monotherapy for 48 weeks. Post-treatment follow-up was for 24 additional weeks. The primary end point was sustained HBV DNA suppression defined as serum HBV DNA<2,000 IU/ml after 24 weeks of post-treatment follow-up. The secondary end point was ALT normalization at the end of follow-up. RESULTS At week 48, HBV DNA was undetectable in 20/30 (67%) in the combination group versus 11/30 (37%) patients in the monotherapy group (P=0.02). ALT normalization was achieved in 17/30 (57%) versus 10/30 (30%) patients, respectively (P=0.03). At week 72, sustained virological response was achieved in 7/30 (23.3%) in the combination group versus 6/30 (20%) patients in the monotherapy group (P=0.75); 5 (16%) patients in each group dropped out because of adverse events or non-compliance. CONCLUSIONS In HBeAg-negative CHB, combination PEG-IFN-alpha2a plus ADV for 48 weeks is safe and resulted in greater on-treatment efficacy than PEG-IFN-alpha2a monotherapy. No difference in sustained virological and biochemical response rates were observed between the two treatment regimens.
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Affiliation(s)
- Paola Piccolo
- Hepatology Unit, Tor Vergata University, Rome, Italy.
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Riggio O, Angeloni S, Salvatori FM, De Santis A, Cerini F, Farcomeni A, Attili AF, Merli M. Incidence, natural history, and risk factors of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt with polytetrafluoroethylene-covered stent grafts. Am J Gastroenterol 2008; 103:2738-46. [PMID: 18775022 DOI: 10.1111/j.1572-0241.2008.02102.x] [Citation(s) in RCA: 180] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The aim of this study was to assess the incidence, natural history, and risk factors of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunt (TIPS) with the new polytetrafluoroethylene (PTFE)-covered stent grafts in cirrhotic patients. PATIENTS AND METHODS Seventy-eight cirrhotic patients treated by TIPS with PTFE-covered stent grafts and followed by the same medical team--according to a prospective protocol for diagnostic workup and surveillance strategy--were reviewed. The follow-up was 19.9 +/- 20.6 months. RESULTS At least one episode of HE occurred in 35 of 78 (44.8%) patients. The probability of remaining free of HE was 53.8% (95% confidence interval [CI] 41.4-66.2] at 1 yr and 50.9% at 2 yr (95% CI 38.2-63.8%). The total number of HE episodes was 89. Fifty-five percent of the episodes were grades III-IV. The occurrence of HE tended to be constant during the follow-up, probably because of the very low incidence of shunt dysfunction (13.6% at 2 yr). Moreover, in six patients, a refractory HE required the reduction of the shunt diameter. One patient died due to variceal bleeding after this procedure. At a multivariate analysis, an older age, high creatinine levels, and low serum sodium and low albumin values were shown to be independent factors for the occurrence of HE. Serum creatinine level was the only variable related to the development of refractory HE at the logistic multivariate analysis. CONCLUSIONS HE after TIPS with PTFE-covered stent grafts is frequent; its incidence is not confined to the first post-TIPS period, but it has the tendency to be frequent over time. Refractory HE occurred in 8% of patients and may be successfully managed by reducing the stent diameter. The selection of patients undergoing TIPS placement should be very accurate, especially for those subjects with abnormal creatinine level.
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Affiliation(s)
- Oliviero Riggio
- II Gastroenterologia, Dipartimento di Medicina Clinica, Sapienza Università di Roma, Rome, Italy
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Mitrevski M, Granata M, Sedati P, Rota F, De Santis A, Remotti D, Callea F, Visentini M. Sterile abscesses complicating monoclonal gammopathy of undetermined significance. Eur J Haematol 2008; 81:246. [PMID: 18410540 DOI: 10.1111/j.1600-0609.2008.01084.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Milica Mitrevski
- Department of Clinical Immunology, S. Camillo-Forlanini Hospital, Rome, Italy
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38
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Carotti S, Morini S, Corradini SG, Burza MA, Molinaro A, Carpino G, Merli M, De Santis A, Muda AO, Rossi M, Attili AF, Gaudio E. Glial fibrillary acidic protein as an early marker of hepatic stellate cell activation in chronic and posttransplant recurrent hepatitis C. Liver Transpl 2008; 14:806-14. [PMID: 18508359 DOI: 10.1002/lt.21436] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Activated alpha-smooth muscle actin (alpha-SMA)-positive hepatic stellate cells (HSCs) are pericytes responsible for fibrosis in chronic liver injury. The glial fibrillary acidic protein (GFAP), commonly expressed by astrocytes in the central nervous system, is expressed in vivo in the liver in a subpopulation of quiescent stellate cells. In the rat, increased GFAP expression in the acute response to injury and down-regulation in the chronic response have been observed, whereas reports concerning GFAP expression in human liver are still conflicting. We investigated the utility of GFAP compared to alpha-SMA as an immunohistochemical marker of early activated HSCs in chronic and posttransplant recurrent hepatitis C and correlated GFAP expression with vascular remodeling and fibrosis progression. With immunohistochemistry and a semiquantitative scoring system, the expression of GFAP and alpha-SMA in HSCs and the microvessel density were analyzed in biopsies from normal livers obtained from cadaveric donors [donor liver (DL); n = 21] and from livers from posttransplant hepatitis C virus recurrent hepatitis (HCV-PTR) patients (n = 19), hepatitis C virus chronic hepatitis (HCV-CH) patients, (n = 12), and hepatitis C virus cirrhosis (HCV-C) patients (n = 16). The percentage of alpha-SMA-positive HSCs was significantly higher in the HCV-PTR, HCV-CH, and HCV-C groups compared to the DL group (P < 0.01). The percentage of GFAP-positive HSCs was significantly higher in the HCV-PTR group compared to the DL, HCV-C (P < 0.01), and HCV-CH (P < 0.05) groups and in the HCV-CH group compared to the DL group (P < 0.01), inversely correlating with the extent of fibrosis and microvessel density (P < 0.01). In the HCV-PTR group, the percentage of GFAP-positive HSCs correlated with fibrosis progression (P < 0.01). In conclusion, GFAP could represent a useful marker of early activation of HSCs in HCV-CH and seems to predict fibrosis progression in HCV-PTR.
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Affiliation(s)
- Simone Carotti
- Department of Human Anatomy, University of Rome La Sapienza, Italy, Rome
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Onori P, Alvaro D, Floreani AR, Mancino MG, Franchitto A, Guido M, Carpino G, De Santis A, Angelico M, Attili AF, Gaudio E. Activation of the IGF1 system characterizes cholangiocyte survival during progression of primary biliary cirrhosis. J Histochem Cytochem 2006; 55:327-34. [PMID: 17164408 DOI: 10.1369/jhc.6r7125.2006] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We evaluated the IGF1 system in cholangiocytes of primay biliary cirrhosis (PBC) patients and investigated the relationships with apoptosis. Biopsies of PBC patients (n=32) and normal subjects (n=5) were investigated by immunohistochemistry for expression in cholangiocytes of IGF1, IGF1-R, pAKT, terminal deoxynucleotide transferase end labeling (TUNEL), Bax (proapoptotic protein), and Bcl2 (antiapoptotic protein). Whereas normal cholangiocytes were almost negative, cholangiocytes of PBC patients showed strong IHC staining for IGF1, IGF1-R, and pAKT, which increases from stage I to stage IV, where >70% of cholangiocytes were positive. Bax/Bcl2 ratio reached the highest value (4.6) in PBC stage III when apoptosis is maximal (24% TUNEL positivity), whereas it declines in stage IV (1.4) when only 7.8% cholangiocytes were TUNEL positive. In PBC stages III and IV, expression of IGF1, IGF1-R, and pAKT in cholangiocytes was directly correlated with the antiapoptotic Bcl2 and inversely correlated with proapoptotic Bax, Bax/Bcl2 ratio, and TUNEL positivity. In conclusion, cholangiocytes of PBC patients showed a marked increase in IGF1, IGF1-R, and pAKT expression involving most cholangiocytes surviving in the terminal ductopenic stage. This was associated and correlated with a balance of pro- and antiapoptotic proteins favoring survival rather than apoptosis, suggesting a major role of IGF1 system in promoting cholangiocyte survival.
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Affiliation(s)
- Paolo Onori
- Department of Experimental Medicine, University of L'Aquila, Italy
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Alvaro D, Barbaro B, Franchitto A, Onori P, Glaser SS, Alpini G, Francis H, Marucci L, Sterpetti P, Ginanni-Corradini S, Onetti Muda A, Dostal DE, De Santis A, Attili AF, Benedetti A, Gaudio E. Estrogens and insulin-like growth factor 1 modulate neoplastic cell growth in human cholangiocarcinoma. Am J Pathol 2006; 169:877-88. [PMID: 16936263 PMCID: PMC1698823 DOI: 10.2353/ajpath.2006.050464] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We investigated the expression of estrogen receptors (ERs), insulin-like growth factor 1 (IGF-1), and IGF-1R (receptor) in human cholangiocarcinoma and cholangiocarcinoma cell lines (HuH-28, TFK-1, Mz-ChA-1), evaluating the role of estrogens and IGF-1 in the modulation of neoplastic cell growth. ER-alpha, ER-beta, IGF-1, and IGF-1R were expressed (immunohistochemistry) in all biopsies (18 of 18) of intrahepatic cholangiocarcinoma. ER-alpha was expressed (Western blot) only by the HuH-28 cell line (intrahepatic cholangiocarcinoma), whereas ER-beta, IGF-1, and IGF-1R were expressed in the three cell lines examined. In serum-deprived HuH-28 cells, serum readmission induced stimulation of cell proliferation that was inhibited by ER and IGF-1R antagonists. 17beta-Estradiol and IGF-1 stimulated proliferation of HuH-28 cells to a similar extent to that of MCF7 (breast cancer) but greater than that of TFK-1 and Mz-ChA-1, inhibiting apoptosis and exerting additive effects. These effects of 17beta-estradiol and IGF-1 were associated with enhanced protein expression of ER-alpha, phosphorylated (p)-ERK1/2 and pAKT but with decreased expression of ER-beta. Finally, transfection of IGF-1R anti-sense oligonucleotides in HuH-28 cells markedly decreased cell proliferation. In conclusion, human intrahepatic cholangiocarcinomas express receptors for estrogens and IGF-1, which cooperate in the modulation of cell growth and apoptosis. Modulation of ER and IGF-1R could represent a strategy for the management of cholangiocarcinoma.
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Affiliation(s)
- Domenico Alvaro
- Department of Clinical Medicine, Division of Gastroenterology, University of Rome, via R. Rossellini 51, 00137 Rome, Italy. domenico.alvaro@uniroma1
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Abstract
AIM: To evaluate the influence of familiality on the prevalence of gallstone disease (GD) in Italy.
METHODS: Families of 79 subjects with gallstones (cases) and of 79 subjects without gallstones (controls) were investigated for the presence of gallstones by ultrasonography. Index cases and index controls were matched for age, sex, and operative unit. Sixty-three and sixty-two husbands and wives of index cases and index controls, respectively, were also studied.
RESULTS: Overall,the prevalence of GD was significantly higher ( χ2=14.52, P<0.001) in the 202 first-degree relatives of subjects with gallstones than that in the 201 first-degree relatives of subjects without gallstones (28.6% vs 12.4%, relative risk (RR) 1.80, 95% confidence interval (CI) 1.29-2.63). In particular, prevalence of GD was significantly higher in mothers, fathers, and sisters of index cases than that in the respective family members of index controls. The highest RR was observed in mothers (RR=2.35, 95%CI 1.38-4.3). Prevalence of GD was not obviously different in brothers and also in husbands and wives of index cases and index controls. Family members of index cases did not differ from family members of control cases with respect to the most important risk factors for gallstones (age, diabetes, BMI, and number of pregnancies) with an exception of a higher prevalence of diabetes in fathers of index controls than in fathers of index cases.
CONCLUSION: This study confirms that familiality plays a very important role in the pathogenesis of gallstones.
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Fimognari FL, De Santis A, Piccheri C, Moscatelli R, Gigliotti F, Vestri A, Attili A, Violi F. Evaluation of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis. ACTA ACUST UNITED AC 2005; 146:238-43. [PMID: 16194685 DOI: 10.1016/j.lab.2005.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2004] [Revised: 03/16/2005] [Accepted: 06/01/2005] [Indexed: 12/29/2022]
Abstract
D-dimer and factor VIII levels raise in advanced cirrhosis. We investigated the behavior and the diagnostic usefulness of D-dimer and factor VIII in cirrhotic patients with asymptomatic portal venous thrombosis. Factor VIII coagulant and D-dimer values were measured in 136 consecutive outpatients with stable cirrhosis divided according to Child-Pugh (CP) classification, who underwent color/power ultrasonography to detect portal thrombosis. Portal thrombosis was found in 33 patients (24.2%). In patients without thrombosis, factor VIII was significantly higher in CP class C compared with class A and B. Conversely, class C patients with portal thrombosis had lower factor VIII levels than those without thrombosis. In both groups, D-dimer was significantly increased in class C compared with class A and B. In class C, thrombotic patients showed higher D-dimer values than did patients without thrombosis. In class C, a D-dimer value > or = 0.55 microg/mL provided a sensitivity and a negative predictive value for portal thrombosis of 100%, and a factor VIII coagulant level < or = 80% showed a specificity and a negative predictive value of 76% and 84%, respectively. In class B, a D-dimer value > or = 0.225 microg/mL had a sensitivity of 89% and a negative predictive value of 82%. In conclusion, our study shows that factor VIII values increase in severe cirrhosis but significantly decrease in the presence of concomitant portal thrombosis, likely because of consumption during thrombosis; D-dimer is enhanced by both liver failure and portal thrombosis; in severe cirrhosis, normal D-dimer and factor VIII values may safely exclude the presence of asymptomatic portal thrombosis.
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Affiliation(s)
- Filippo Luca Fimognari
- Division of Internal Medicine, ASL Roma G/Parodi-Delfino Hospital, Colleferro, Rome, Italy
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Alvaro D, Invernizzi P, Onori P, Franchitto A, De Santis A, Crosignani A, Sferra R, Ginanni-Corradini S, Mancino MG, Maggioni M, Attili AF, Podda M, Gaudio E. Estrogen receptors in cholangiocytes and the progression of primary biliary cirrhosis. J Hepatol 2004; 41:905-12. [PMID: 15645536 DOI: 10.1016/j.jhep.2004.08.022] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND/AIMS Estrogen receptors (ER) in cholangiocytes of primary biliary cirrhosis (PBC) patients and their relationship with cell proliferation and death were evaluated. METHODS Liver biopsies from PBC patients with different histological stages were investigated by immunohistochemistry for ER-alpha and -beta, cytokeratin-19, proliferating cellular nuclear antigen (PCNA), Fas and terminal deoxynucleotide transferase end labelling (TUNEL). Normal livers and livers from primary sclerosing cholangitis and alcoholic cirrhosis were investigated as controls. RESULTS ER-alpha and -beta were observed in cholangiocytes of PBC patients but not in normal liver. In PBC, positivity for ER-beta was high (50-65 %) in all histological stages while, positivity for ER-alpha increased from 1% in stage I to 12 % in stage III (positivity correlated and co-localized in the same cell with PCNA). In stage IV of PBC, cholangiocytes were negative for ER-alpha in association with a lower PCNA positivity and with maximal degree of ductopenia. ER-alpha positivity in cholangiocytes of PBC patients was markedly lower than primary sclerosing cholangitis and alcoholic cirrhosis. CONCLUSIONS ER are expressed in PBC and other pathologies associated with cholangiocyte proliferation but not in normal subjects. The low expression of ER-alpha in PBC and their disappearance in the advanced histological stages suggests that an estrogenic deficiency could favour the evolution of this disease toward ductopenia.
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MESH Headings
- Apoptosis
- Bile Ducts, Intrahepatic/metabolism
- Bile Ducts, Intrahepatic/pathology
- Biomarkers/metabolism
- Case-Control Studies
- Cell Division
- Cholangitis, Sclerosing/metabolism
- Cholangitis, Sclerosing/pathology
- Cholangitis, Sclerosing/physiopathology
- Disease Progression
- Estrogen Receptor alpha/metabolism
- Estrogen Receptor beta/metabolism
- Humans
- Immunohistochemistry
- Liver/metabolism
- Liver/pathology
- Liver Cirrhosis, Alcoholic/metabolism
- Liver Cirrhosis, Alcoholic/pathology
- Liver Cirrhosis, Alcoholic/physiopathology
- Liver Cirrhosis, Biliary/metabolism
- Liver Cirrhosis, Biliary/pathology
- Liver Cirrhosis, Biliary/physiopathology
- Proliferating Cell Nuclear Antigen/metabolism
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Affiliation(s)
- Domenico Alvaro
- Division of Gastroenterology, Department of Clinical Medicine, University of Rome, La Sapienza, via R. Rossellini 51, 00137 Rome, Italy.
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Angeloni S, Merli M, Salvatori FM, De Santis A, Fanelli F, Pepino D, Attili AF, Rossi P, Riggio O. Polytetrafluoroethylene-covered stent grafts for TIPS procedure: 1-year patency and clinical results. Am J Gastroenterol 2004; 99:280-5. [PMID: 15046218 DOI: 10.1111/j.1572-0241.2004.04056.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Polytetrafluoroethylene (PTFE)-covered stent grafts appear to have the potential to improve TIPS patency, but data available are few and controversial. The aim of this prospective nonrandomized trial was to assess TIPS safety and 1-yr patency with a new commercially available PTFE-covered stent graft in comparison with a group of historical controls treated with conventional stents. METHODS Between July 1992 and December 1999, 87 consecutive cirrhotics underwent TIPS with conventional stents, while from January 2000 to November 2001, 32 consecutive cirrhotics were treated with PTFE-covered stent grafts. All patients were followed by the same medical team according to a prospective protocol for a diagnostic work-up and a surveillance strategy. RESULTS The two groups were comparable for age, sex, etiology, and severity of cirrhosis. The 1-yr probability of remaining free of shunt dysfunction tended to be higher in the covered stent group: 76.3% (95% CI = 58.7-93.9%) versus 57.5% (95% CI = 46.6-68.4%); log rank test: p = 0.055. However, stenoses inside the stent were significantly higher in patients with bare stents (88% vs 17%), while stenoses at the hepatic or portal vein were more frequent in PTFE-covered stent-graft group (50% vs 9% and 33% vs 3%, respectively), (chi2 = 15.42; df = 2.0; p = 0.0004). Stenoses inside the covered portion of the stent did not occur. One-year cumulative rebleeding, encephalopathy, and survival were similar. CONCLUSIONS PTFE-covered stents are able to solve pseudointimal hyperplasia within the stent tract, but have a high incidence of hepatic or portal vein stenosis. Improvements in stent design and insertion techniques are necessary to fully achieve the potential benefit of this new device.
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Affiliation(s)
- Stefania Angeloni
- II Gastroenterologia, Dipartimento di Medicina Clinica, Università di Roma "La Sapienza", Italy
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Abstract
BACKGROUND/AIMS The incidence and natural history of small esophageal varices (EV) in cirrhotics may influence the frequency of endoscopies and the decision to start a pharmacological treatment in these patients. METHODS We prospectively evaluated 206 cirrhotics, 113 without varices and 93 with small EV, during a mean follow-up of 37+/-22 months. Patients with previous gastrointestinal bleeding or receiving any treatment for portal hypertension were excluded. Endoscopy was performed every 12 months. RESULTS The rate of incidence of EV was 5% (95%CI: 0.8-8.2%) at 1 year and 28% (21.0-35.0%) at 3 years. The rate of EV progression was 12% (5.6-18.4%) at 1 year and 31% (21.2-40.8%) at 3 years. Post-alcoholic origin of cirrhosis, Child-Pugh's class (B or C) and the finding of red wale marks at first examination were predictors for the variceal progression. The two-years risk of bleeding from EV was higher in patients with small varices upon enrollment than in those without varices: 12% (95% CI: 5.2-18.8%) vs. 2% (0.1-4.1%); (P<0.01). Predictor for bleeding was the presence of red wale marks at first endoscopy. CONCLUSIONS In patients with no or small EV, endoscopy surveillance should be planned taking into account cause and degree of liver dysfunction.
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Affiliation(s)
- Manuela Merli
- II Gastroenterology Unit, Department of Clinical Medicine, University of Rome La Sapienza, Viale dell'Università 37, 00185 Rome, Italy.
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